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.Applications Wiil-Be'Processed When Submitted Properly Complete" u T g Application. <br /> .1FOR OFFICE USE: APPLICATIO dV f <br /> y iJ _ = (For Non-Transferable, Rev e, 1srldable) O ` <br /> PUMP&WELL <br /> ENVIRONMENTAL H H P�J ITIV . 3 <br /> ' WATER UAL 1 ! ' <br /> (COMPLETE IN TRIPLICATE) - Q 1l� `(��-C i <br /> A''pplIcation1sherebymado totheSanJoaquinLocaIHeaIthDistrictforapermittoccnstructa d/t�F�t�s�ta C--,e p%\qereindescribed.ThisappIicationis <br /> made in compliance wit J aeVIn County Ordinance No. 1862 and the rules and ri�R 10he San ui Loc I�-HT-eal�th�pisYr ct. <br /> Exact Site Address"' d ✓�� G H ity/Town , <br /> �f , C <br /> Owner's Name / Phone <br /> Address • City <br /> Contractor's <br /> rte _ l <br /> Contractor's Name �,,���04� �_ �� License# 3�Busi ss Phone ' d <br /> Contractor's Address J�' Emergency Phone <br /> Is1'Certificate of Workman's Compensation insurance on File With SJLHD? Yes V No a i <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 i Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i <br /> I Property Linef Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL . <br /> ❑I INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> /❑� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑'DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑l IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ) <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> QI DISPOSAL ❑ OTHER Other Information <br /> r <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: tDion 11 701 gX"-All <br /> DESTRUCTION OF WELL: a <br /> Describe Material and Procedure <br /> J� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C <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 forwhich this permit <br /> is issued, I shall'not employ any person in such manner as to become su ct to workman's compensation laws of California." <br /> Contractor' ring or sub-contracting signature certifies the following:' c ify that in the performance of the work forwhich this <br /> i p I s ed, i s II employ er ns subject to workman's comp n ion laws of California." <br /> I I will_ t Inspection l rio to grouting and a final inspe Ion. ) <br /> Signed X Titl Date: �V� <br /> !I]: (Draw Plot Plan on Reverse.Side) v <br /> FOR DEPARTMENT USE ONLY <br /> PHASEIX� <br /> Application Accepted By ` '�^ Dated `! <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By 1To� Date Inspection By Ylk;� Date ~" <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &.Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> iBILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT pUE CHECKED A <br /> AMOUNT <br /> FEE 1 <br /> LESS <br /> PRORATION jNgNgNq <br /> PLUS <br /> i PENALTY ' <br /> OTHER 1 <br /> ' OTHER <br /> Received by. Date t Receipt No. Permit No. Issu nce Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br /> ;I]: r t, <br />