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, Ap I ions Will Be sP�rocg WhenSubmittedProperly Completed..8e Sure To Sign The Application. <br /> FOR OFFICE USE: huh e�® �� APPLICATION <br /> (For r}�Tranaferable, Revocable, 5uspendable) PUMP&WELL <br /> 10,P0,biAtty0ONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) ' WATER QUALITY_ <br /> . m <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordi e No..1862 and the rules and regulations of the San J *n Loc H Ith District. <br /> Exact Site Address City/Town 'IIr_�_ - <br /> Owner's Name Phone <br /> Address .'r City-usiness <br /> C ,~ moo <br /> Contractor's Name i -License Phone l 7 <br /> 9 7 Y <br /> Contractor's Address44,47220­4=7Emergency Phone - � at <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ 'RECONDITION❑ DESTRUCTION Z____ y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 'k-Other <br /> k <br /> a 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 ❑ 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 4 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL % Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: rr .e ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter— e., . Approximate Depth <br /> Describe Material and Procedure F <br /> r <br /> I hereby certify that I have prep66d this application and that the work will be done in accordance wi an 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this 1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> call or a Grout Inspection prior t outing and final inspecti <br /> Signed Title Date: 2 <br /> (Draw Plot Plan on Reverse Side) <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> 30 <br /> Application Accepted By A- °�- �'�-�^ Date �� <br /> l <br /> Additional Comments: <br /> Phase It Grout Inspectiona III F' al Inspection <br /> Inspection By �R Date Inspection By � Date 2 —,92, <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UWT ❑ PER SITE ❑ EACH ❑ January 1 &Received By JanuaFY 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Dr� t' /0,5_1 <br /> LESS e i• - <br /> PRORATION i a <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> / Q 30 ?� <br /> Received by Date Receipt No. - Permit No. -I5 ante lbate Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />