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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> c FOR OFFICE USE: APPLICfix <br /> ATiV <br /> (For Non-Transfera bi�,1e b%1b T gibe PUMP&WELL <br /> U <br /> ENVIR %\, ESII�TAL M"IlEALTH PER T <br /> (COMPLETE IN TRIPLICATE) ATER QU,"TT <br /> Application is hereby made to the San Joaquin Local HealthDistrico ape t;constructant �+ � ` <br /> ��stallthework,herein described.This application is <br /> made in compliance with San Joaquinh Cho ty Or inance�o. 1862 and the rules Ejnd u'ta of the San Joaquin Local Health District. <br /> Exact Site Address 7`7' l -° CL r- rLe-r,.- tr (_ sem . <br /> t v Town C <br /> Owner's Name Lt` <br /> Address —III G.._ � �- <br /> )T GL Phone 3 r. <br /> rl t.a City - C) <br /> Contractor's Name Mt License# q` 640 Business Phone• ^t'� 142- W <br /> Contractor's Address ° Q Emergency Pho eLa 2.- 142'-� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ bESTRUCTIO�N,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER El PUMP INSTALLATION is/ PUMP REPAIR❑ <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 Well Public Domestic Well <br /> INTENDED USE TYPE-OF WELL• <br />- ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> DOMESTIC/PRIVATE 13DRILLED• - Dia. of Well Casin <br /> ❑ DOMESTIC/PUBLIC F 11 DRIVEN g <br /> 1:1 IRRIGATION �•-❑ _ - Gauge of Casing <br /> GRAVEL PACK r Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ) <br /> ❑ GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (AQ - hQd <br /> Type of Pump G 3 H P �i <br /> PUMP REPLACEMENT: V State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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. p <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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." <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 /> r. <br /> I will call f rout Inspection to gr ting d a final inspection. <br /> Signed X Titl Date` <br /> a <br /> {Draw Plot Plano everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> #•PHASE l _ <br /> Application Accepted oal Comments:By <br /> 'Additional Date <br /> Phase II Grout Inspection PhaseII Final Inspection <br /> Inspection By <br /> ��� Date Inspection By�r pate � t <br /> Fee W Gue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION - .BILLING REMITTANCE $ REMIT , <br /> DATE DATEREMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by `-Date -�-- .Receipt No. Permit No. suanc Date mailed Delivered— <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> C <br />