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... Applications Will Be Processed When Submitted Properly compmea. <br /> FOR OFFICE USE: APPLICATION `" AUG 23 1979 � <br /> (For Non-Transferable, Rer&able;'Suspendable) <br /> , ? PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN J0AQUIN WCAL <br /> ' a( 4.o11e' WATER.QUALITY HEALTH DSTn9CT S <br /> (COMPLETE IN TRIPLICATE) /t'�o y a <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with n rho Or inance . 1862 and the rglgs a los f the San uin cal Ith istrict. <br /> Exact Site Address Cyd City/Town9 <br /> Owner's Name <br /> ft/2_- ��� X11? � Phone �7 <br /> Address City <br /> Contractor's Name �L� License# Business)h e <br /> Emergency Phone <br /> "' W <br /> Contractor's Address �j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� m <br /> TYPE OF WORK (CHECK): NEW WELL L1� DEEPEN El RECONDITION❑ DESTRUCTIOON❑ Ya <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �� PUMP REPAIR❑ <br /> 'REPLACEMENT❑ Q� ��'� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field f"' Cesspool/Seepage Pit �` Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ II �USTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> CJ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> k ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 51'ROTARY <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL <br /> Surface Seal Installed By: L C� <br /> ❑ � M 5 <br /> i PUMP INSTALLATION: Contractor .��-,_-T <br /> Type of Pump U H.P. <br /> t PUMP REPLACEMENT: ❑ State Work Done <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's h' 'ng or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit i ed, I shall e p o persons subject to workman's compen Ion laws of California." <br /> I rout In ecti rior to grouting and a final lnspe on. y �. y <br /> Title: <br /> Date: <br /> + Signed X <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> C Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phas 11 Final Inspection <br /> + By ate Inspection By Date <br /> Inspection <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 '❑ July 1 &Receiv FEMITBy uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> V FEE _ <br /> k LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPL_(CANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />