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r ApplicationsWill Be Processed When Submitted Properly� �t+{��ySL e4 SW9 7�plication. <br /> �EO"FfICE USE. APPLICA 1L�J� 1�i F� <br /> (For Non-Transferable, Revoc Suspendable) �np0 <br /> • ��iJO PUMP&WELL <br /> ENVIRONMENTAL HEALTH PT�' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY A <br /> OW01LO����C++AL <br /> ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittocnstr pl to t6Tw9W?Ti rein described.This application is <br /> made in compliance w o ain �SGnt rdinance No. 1862 anc e r les and reIHioo�In..s of the San a uin l oc E H It strict. <br /> Exact Site Address "7 ��O City/Town A <br /> 11 <br /> Owner's Nam Phone <br /> L <br /> I" Address 41 City <br /> t Contractor's Named t U License Busi ss Pho <br /> f Contractor's Address J'/ T Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit 4 Other <br /> Property Line Private Domestic Well Public Domestic Well`, <br /> INTENDED USE TYPE OF WELL <br /> ❑iYf�1DUSTRIAL 11CABLE TOOL Dia, of Well Excavation . <br /> 'U DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> o ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t{f <br /> i PUMP INSTALLATION: Contractor <br /> ,Type of Pump H.P. V� <br /> PUMP REPLACEMENT: ❑ State Work Done.- <br /> PUMP REPAIR: t tate Work Done �1 <br /> DESTRUCTION OF WELL: I Well DiameterC <br /> Approximate Depth <br /> Describe Material and Procedure <br /> ------------ <br /> `I A <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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's h` ' g or sub-contracting signature certifies the following."I certify that in the performance of the work for which this <br /> per i ed, I shall em by rsons subject to workman's compensa ` laws of California." <br /> I ill ut Insp ciion rior to grouting and a final inspectio <br /> Signed X Title: <br /> - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> I <br /> PHASE I FOR DEPAR. ENT USE ONLY � <br />` j) <br /> � <br /> Application Accepted By <br /> -" Date <br /> Additional Comments:-_ <br /> Phase 11 Grout Inspection � v C- Phase III Final Inspection <br /> Inspection By Date ec'tion By date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT WPER SfTE ❑ EA � ❑ January 1 &Received By January 31 ❑ July 1 &Received By-July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REWTTANCE $ _I <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> r <br /> FEE yy <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> r <br /> L. <br /> OTHER <br /> Received by - Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />