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Ap ic"1� IoI Be P ocessed Wh"bmitted Properly Completed, Be SureToSignTheAppllcan°E <br /> FOR OFFICE USE: APPLICATIQN <br /> a 43 (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> lNMENTAL HEALTH•PERMIT <br /> n �j -� l5tiRkOWATER QUALITY <br /> (COMPLETE IN TRIPLICATE) P - r�" � <br /> Application is hereby made to the Sa�aquln Local Health District fora permit to construct and/or iristall the work herein described-This application is <br /> made in compliance.wi h San Joaquin County Ordinance No. 1862,and therulesand regulations of the San Joan LLoo�caal Health District. <br /> ` City/Town <br /> Exact Site Addressf! ` u <br /> _ r. Phone <br /> Owner's NamarCit <br /> e <br /> ,.; .:,. .4�r, �.; � y -on <br /> Address ��_ j r Business Phone <br /> License# <br /> Contractor's Name Emergency Phone <br /> Contractor's Address = � No <br /> Is Certificate of Workman's Compensation In on File With S-RECONDITION <br /> ECO Yes n ,. <br /> TYPE OF WORK (CHECK): NEW WELL❑ABANDONMENT 0❑ OTHER O❑ ITI PUMP INSTALLATIESTRLION ❑❑� PUMP REPAIR.1k <br /> WELL CHLORINATION ❑ WELL <br /> REPLACEMENT❑ Pit Privy Y <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> -Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE r TYPE OF WELL <br /> 11 INDUSTRIAL <br /> 13 CABLE TOOLr Dia. of Well Excavation .i <br /> 11DOMESTIC/PRIVATE 13 DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC y ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal. <br /> ❑ CATHODIC PROTECTION 11ROTARY Type of Grout Y <br /> f ❑ DISPOSAL <br /> 11 OTHER Other Information <br /> 4 Surface Seal Installed By: <br /> 11 GEOPHYSICAL + <br /> k PUMP INSTALLATION: Contractor _ <br /> N.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: I❑n� State Work Done <br /> Ia , <br /> j PUMP REPAIR: StApproximate Depth <br /> ate Work Don <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> t .. <br /> I 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 performance of the work for which this permit <br /> is issued, I shall not employ anyperson 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 forwhich this <br /> permit is issued, I shall employ'persons subject to workman's compensation laws of California." .. <br /> 1 will call fora."ut Inspection prior to grouting and a final inspectiopn <br /> Signed X Title: n .� - � _ Date: <br /> (Draw Plot Plan on Reverse�5ide} <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> ' Application Accepted y <br /> Additional Commen hose III Fin nspecifon <br /> Phase 11 Grout Inspection <br /> Date <br /> Inspection By <br /> Date <br /> inspection By <br /> Insp <br /> I ❑ Januar 1 &Received By January 31 - ' ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT El SITE ❑ EACH y REMIT -- <br /> BILLING ': REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE, EXPLANATION DATE DATE 'REMITTED AMOUNT - <br /> y FEE <br /> -LESS <br /> I <br /> PRORATION , <br /> I PLUS - - <br /> PENALTY <br /> OTHER t <br /> OTHER <br /> "141 <br /> Permit No. Issua ce.Date Mailed Delivered' - -- — — <br /> 'Received by Date s. y-=Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />