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Ap . of s, dyke s ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: } f I APPLICATION <br /> {For ansferable, Revocable,Suspendable) PUMP&WELL <br /> W10V 2 2 ZNVIRONMENTAL HEALTH PERMIT <br /> w' UA{COMPLETE IN TRIPLICATE QUALITY <br /> i WATER Q �. <br /> Application is hereby made t Man ` AAUa=f%4istrictforapermittoconstructand/or instal I the work.herein described.This application is <br /> made in compliance with San JK ° w1n TFJ1zT o. 186 2 and the rules and regulations of theSan;Joaquin Local Health District. , <br /> Exact Site Address o� QQ City/Town--Ma tCihlNIJOLCQ, ' <br /> Owner's Name �.�� _ C�Lg''� Pho i <br /> Address ► } City'' (fir <br /> Contractor's Name License# rT <br /> fQ Gsiness'PFtone <br /> � <br /> Contractor's Address Emergency I <br /> Is Certificate of Workman's Compensate n Insurance on File With SJLHD? Yes 4N No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP .INSTALLATION ❑ PUMP REPAIR C1 Q` <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 We111 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 r i Gauge of Casing <br /> ❑ IRRIGATION -4 ❑ GRAVEL PACK ` --" Depth of Grout Seal 4 �Xl ' <br /> r ❑ CATHODIC PROTECTION ❑ ROTARY ,, { Type of Grout " ( ! <br /> ❑ DISPOSAL ❑ OTHER e Other Information I <br /> I ❑ GEOPHYSICAL .� , �,Ejurface, lnstalled,,By:;. y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4i P <br /> PUMP REPLACEMENT: State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> I hereby-ce'rtify that9 have-prepared this application'and-thatthe'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. / rx ", ! <br /> * <br /> Homeowner oi.licensed ageht's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, 1`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." <br /> I II for a Grout Inspe pri o gro ng and a final inspection. <br /> Signed X Title:. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE'ONLY <br /> PHASEIy` _ <br /> Application Accepted By va> <br /> r Additional Comments: <br /> Phase II Grout Inspection h e III Final Inspection! <br /> Inspection ByQ i. � Date Inspection By Date <br /> �'\ i <br /> Fee Is Due: 1:1ANNUALLY C1PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31- <br /> REMIT <br /> 'BILLING REMITTANCE $ <br /> SASE 'EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS i' (*,I ho'- <br /> PRORATION <br /> o PRORATION <br /> PLUS <br /> PENALTY f 2— 0 �/+ �'!� I�Y�CSU <br /> 1 <br /> OTHER " <br /> OTHER <br /> Wo� 1 .- <br /> Received by Date Receipt No. -Permit No. Issuafrice Date Mailed Delivered <br /> + APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201 <br />