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A j64at1as)Mlll Be ProcessedI ubmitted Properly Completed. Be Sure To Sign The Application. <br /> JULOR OFFICE USE: 1 q 198 APPLICATION <br /> t +a L3 or Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> SAN J QUIN L�ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)tlEA TIJ DISTRICT WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/orinstall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and therulesand regulations of the San Joa uin Loc I Health District. <br /> Exact Site Address / e �C7 V A City/Town A4bJ { <br /> �. <br /> Owner's Name � O � Phone- <br /> Address City SG. <br /> Contractor's Name T License# 196.10 Business Phonej <br /> Contractor's Address Emergency Phone ihn <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—AYA No ) <br /> TYPE OF WORK (CHECK): ' NEW WELL DEEPEN ❑ RECONDITION 1:1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENTQ <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 ❑ <br /> y CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE "" - ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC r ❑ DRIVEN Gauge of Casing *` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY I Type of Grout Q >, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �1 <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 4 19 State Work DoneA7�� � <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 performance of the work for which 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." .4 <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 wil Il for Grout I c'o pNar to grouting and a final inspection f j <br /> Signed X Title: Date: / / r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> Application Accepted By --�� tf P.u_ �b Dateo <br /> Additional Comments: <br /> WIroutpection as III Final Inspection <br /> Inspection ByDate Inspection By ° DateFee Is Due: ❑ ANNUAL ❑ PER SITE -❑ EACH O'January 1 8 Received By January 31 July, 1 R Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> ' DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE /C <br /> LESS �f V <br /> PRORATION - <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER I <br /> Received by Date'- Receipt No. - Permit No. Issuance Date - Mailed Delivered– <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 -5T6CKT0N,CA 95201 - <br />