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JA <br /> �li�ati s W111 tae Processe n Submitked Properly Completed. a ure o gnFOR OFFICE tt;;rr APPLICATION <br /> �Ut`, � (For Non-Transferable, Revocable, Suspendable) PUMA&WELL <br /> �_01RWRONMENTAL HEALTH PERMIT <br /> {COMPLETE IN TRIPLICA j�LT� <br /> Gt� WATER QUALITY �k: w ,_ <br /> Applicationisherebymadetot eSanJoaquinLocalHealthDistrictforapermittoconstructand/or install thework,herelndescribed.Thisapplicationis <br /> made in compliance with$an Joaquin County Ordinance No. 1862 and the .rules and regulations of the San Joaquin Local Health District.. r <br /> q � City/Town <br /> Exact Site Address <br /> Phone r 7 <br /> Owner's Name 70 <br /> City <br /> Address r, r, �a Business'Phone <br /> Contractor's Name License# <br /> Contractor's Address CJ1_ tl' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK(CHECK): WELEW L ABANDONMENT ❑DEEPEN ❑ OTHER 13 ITIO UDP DESTRUINSTALLATION ❑ PUMP REPAIRS <br /> WELL CHLORINATION W I <br /> REPLACEMENT❑ C7 <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> LrI DOMESTIG/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor + <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <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 /> C Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> 4�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." v <br /> 1 wilitcall for a out Inspecttipon prior to grouting and a final inspection. <br /> Signed X <br /> 1 / ,.Areg – Title: Date: <br /> (Draw Plot Plan on Reverse Side) 1 <br /> a, <br /> FOR DEPARTMENT.USE ONLY <br /> PHASE 1 Wim.. Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection P as III Final Inspection��� — � <br /> Inspection By <br /> Date Inspection B Date <br /> Fee IS Due:.❑ ANNUALLY ❑ PER UNIT ❑- PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f BA8 EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE g, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .i.. <br /> Cp Q. �b <br /> = Received by <br /> Hate Receipt No. -9-� Permit No.%' Issuance Date - Mailed DeRVered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES �,-�1601�E.HAZELTON AVE.,P.O.Box 2009r^STOCKTON,CA 95201 <br />