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Applications Will Be Processed When Submitted Properly Com d. Be Sure To Sign The Attiff`ion. <br /> FOR OFFICE USE: APPLICATIO [� �97g J <br /> (For Non-Transferable, Revocable,SuspendUe <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH MAQUIH LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . HEALTH DISTRICT � <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with,6ayrJn CntxdIn�aYnceNo.186 and the r es and regulations of the San oa uin��HHea tt h D)strict. v <br /> Exact Site, C��j �/���'y r- Lam, City/Townz-1-6 d �rj�J <br /> Owner's Name! P� P �T ��` Phone � <br /> Y <br /> Address �-7Z 6 T City e ✓ <br /> Contractor's Name 7` � 5 License#/Z Business Pho <br /> Contractor's Address " �� 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 L�"f PUMP REPAIR , <br /> REPLACEMENT❑ �` <br /> f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> :Sewage Disposal Field--_.. .��., ..Cesspool/Seepage�At. L. ._ Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL ..Dia. of Well Excavation e , <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED ADia. of Well Casing <br /> ElDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONS ❑ GRAVEL PACKDepth of Grout Seal <br /> ❑ CATHODIC PROTECTIONS '� ❑ ROTARY`S Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other�Information 1 . <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _2k. _ <br /> Type of Pump f ' P. <br /> ® t <br /> PUMP REPLACEMENT: 'State Work Done , <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r 1 Approximate Depth <br /> IL <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and thatthe 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 /> con'racfo ' ring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> Perm sued, I shall e Ioy persons subject 16-workman's cbmpen i�1'awsof California." <br /> E i rout In ec ion'prior to grouting and a final inspec n. J �7 <br /> Signed XTitle ' Date. <br /> l <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEP RTMENT SE ONLY <br /> PHASE I q <br /> Application Accepted By— ^' Date G �/ <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date h <br /> I <br /> Fee IS Due. ❑ ANNUALLY ❑ PER UNIT 1�r PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT !� <br /> BASE- EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> Ap AMOUNT <br /> �FEE s- <br /> LESS <br /> PRORATION }-� <br /> PLUS 1 <br /> PENALTY 2 , <br /> OTHER 1 <br /> OTHER <br /> y 7.: -—k\ 97 1 <br /> Received by Date Receipt No. .Permit No. - Issuance ate Mailed Delivered ^' ,•. + <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-ECHAZELTON AVE.'`P;OrBoe"2009-t S, CKTON i <br />