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Sign <br /> Applications WittBPro� gess}} d-W/he� �StFb�trr4;ed Properly Camped. Be Sure Tohe Application.� <br /> FOR OFFICE USE: \ t� L 1f 1 <br /> PLICATION <br /> (For Non-Trat�1Table, Revocable, Suspendable) <br /> 9n PUMP&WELL <br /> AP R 1,tOiWONMENTAL HEALTH ,PERMIT � ��� <br /> (COMPLETE IN TRIPLICATE) �-•�r�!�! WATER QUALITY ' <br /> Application is hereby made to the Saui�i•L� I'{ 'Itli'{9it;trrdf#or a permit to construct a4LIr install thew herein de ribed, tris application is <br /> made incompliance with S- d' ���RtC/I 2 and the rules and regulations of the Sa M=ne s <br /> Exact Site Add ss CJ Cx. �C�J City/Tow <br /> Owner's Name Phone <br /> Address City <br /> Contractor's N me License# Business <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL B-_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®-' PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy' <br /> Sewage Disposal field Cesspool/Seepage Pit Other i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 1,.,1_,� 11INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED -I ���� Dia. of Well Casing <br /> M f <br /> ❑ DOMESTIC/PUBLIC �,~�pV�' y <br /> ❑ DRIVEN Gauge of Casing � <br /> 13 IRRIGATION 1:1 GRAVEL PACK -� Depth of Grout Seal <br /> i <br /> 11 CATHODIC PROTECTION w�ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur a Sea��Installe�d�By:: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F /4 W CG,�, � 311.E <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's g or sub-contracting signature certifies the following:"I cern - in the performance of the work forwhich this <br /> pe It is i d. I shall employ erso subject to workman's comK <br /> ' ws of California." <br /> I ill r t Inspectio rior o grouting a d a final inspe <br /> Signed X Title: Date: <br /> (Draw Plot Pian on ev - <br /> -FOR DEPARTMENT USE ONLY ��-3/��� �✓�`'l �✓�s <br /> PHASEI <br /> Application Accepted By V�"ti Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectionpection _ <br /> Inspection By Date Inspection By rise III lnal insDate l5 r <br /> j Fee Is Due: ❑ ANNUAILCY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> fff REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> 145) <br /> h <br /> Received by Date Receipt No, Permit No - Issu nce Date Mailed Delivered - <br /> � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERIyIITlSERVICES � 1601 E.HAZELTON AVE.,P.O.Sox 2009 . STOCKTON,CA 45 F <br />