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Applications Will Be Processed When Submitted Properly Completed Be"Ll TO-6i Tplication. <br /> M FOR OFF-',CE USE: APPUCATI I y <br /> (For Non-Transierable, RevocaW) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEA PE�iA�1,T}1YK <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or in�StaH 1��'r'60D e'f m described.This application is <br /> ?•'t=� <br /> made in compliance wlt San Joaquin Co my Ordinance No. 1862 and the rules and r��1Aiof� -o(_th� l oval Health District. <br /> Exact Site Address S3 O C) a /yQ_ ' _ D Hs i �no''ivr, q^ <br /> Owner's Name 14 /45-«m — Phone T 6-3 <br /> Address -1,3E3o .-J, CityT� r <br /> Contractor's Name License 4)6,2 3 73t Business Phone <br /> Contractor's Address 142w, Emergency Phone �K(, <br /> Is Certificate of Workman's Compensation Insuran 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 M--- <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 /> ❑ E] CABLE TOOL Dia. of Well Excavation <br /> NDUSTRIAL <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ®`State Work Done <br /> PUMP REPAIR: ❑ State Work Done 5 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 <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." <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 wi all for a Grout Ins ction prior to grouting and a final inspection. <br /> Signed X _ Date: <br /> (Draw Plot Plan on Bever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I O� -�� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received B a ary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REWTTD AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ! <br /> PLUS <br /> PENALTY Y <br /> OTHER <br /> OTHER <br /> ez <br /> Received by Date Receipt No. Permit No, Issuance Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />