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Appo6rW1i 1'BV1PrbteftedMhemined Properly Completed. Be Sure To Sign The Application. <br /> FOR-131-FICC=USE. APPLICATION <br /> NOVY 30 .k F9 Non- ransferable, Revocable,Suspendable) <br /> PUMP�-WELL � <br /> E VIRONMENTAL HEALTH PERMIT <br /> SAN JOAQU LQWATER QUALITY <br /> (COMPLETE IN TRIPLICATE) HEALTH 41iinstall <br /> f �t <br /> Application is herebymadetotheSanJoaquin o I TDistrictfora eermittoconstructand/or installtheworkhereindescribed.Thisapplicationis <br /> made in compliance with S Joaq in Cou y Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. 6 <br /> Exact Site Address 3 E . :,6-15ty/T6wn <br /> Owner's Name Phone -X�-z5:21 1, <br /> Address 7 City_ 3 <br /> Contractor's Name License#M�aL)Sri Business Phone 8,2-3 <br /> Contractor's Address <�.� ��Zf(c, H�aa�-� r-r-,$3�4 Emergency Phone F <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ 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 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATIO ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PR TECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ff � <br /> ❑ GEOPHYSICAL Surface Seal Installed By: W . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. 'S~ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done -a16,de oo <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth „ <br /> Describe Material and Procedure n <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework forwhich 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." f <br /> I will C Il to a G7eL,_J_ <br /> nspection prior to grouting and a final inspectio {� <br /> Signed X 7Cu' 1 ` -- Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTME T USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection A P a III Final nspection �/ g <br /> Inspection By Date /J Inspection By Date /R^ /` A <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEee_ E—Xetn <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 �-Z <br /> -I <br /> Received by Dfate Receipt No. Per it No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 9520 <br />