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Applications Will Be Processed When Submitted Properly Completed. Be Sur Sign The Application. <br />` Ft ... ._,_USE: APPLICATION y <br /> (For Non-Transferable, Revocably,,, pb;�da ) <br /> VV PUMP&WELL )k#/ENVIRONMENTAL RMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WA UIITY r <br /> Application is hereby made to the San Joaquin Local Health District forap oconj 'Ito /orinstalld rk herein described.This application is <br /> made in compliance with San Joaquin County Ordinan No. 1862 an th S an �Vre�gulhti f�VV`��1 Joaquin Local Health District. <br /> Exact Site Address ( 0 - <br /> 0492, 6.22Z <br /> Owner's Name ,v O Phone <br /> Address A City <br /> Contractor's Name License# Business Phone <br /> I 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 13 DESTRUCTION❑ <br /> WELL CHLORINATION IT WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT 71 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage tit Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r -^ <br /> ❑ INDUSTRIAL "❑CABLE TOOL" "� l Dia. of Well Excavation <br /> F ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ff IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ' El ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information n <br /> ❑ GEOPHYSICAL Surface Seal Installed By: IJ <br /> PUMP INSTALLATION: Gontractor <br /> r, ti <br /> _Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑yState Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County a <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 /> t 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 /> l permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: r Date: _�- 1140 - <br /> •^---(Draw Plot-Plan=on Reverse-Sic!Ev <br /> u FOR DEPART ENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date �� <br /> Additional Comments: <br /> Phase 11 Grout Inspection—;^- � f'°' h e inal In pec ion � <br /> I Inspection By = -Pate�w�` µ Inspection.By' Date G w' <br /> f <br /> '07 <br /> Fee I5 Due: 1:1 ANNUALLY ❑ IT <br /> PER UNIT PER'S ❑ EACH ❑ January.l &Received By January 31 C1 July 1 B Received By July 31 <br /> .. f r REMIT <br /> BASE EXPLANATION BILLING -'REMITTANCE AMOUNT DUE CHECKED <br /> ' DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS + fi <br /> - PRORATION "{ - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ! 3 W <br /> Received by Date Receipt No Permit No. I suanc Date Mailed Delivered <br /> {.: APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE'P.O.Box 2009 STOCKTON,CA 95291 <br />