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cations Will Be ProcessedbWSubmittedProperlyt;ompterea. oeaura <br /> 71EE1iEALfH <br /> AUG `301982 APPLICATION <br /> !� (For Non-Transferable, Revocable, Suspendabie) <br /> PUMP&WELL <br /> ATS ;o tQU' N L�}RONMENTAL HEALTH PERMIT <br /> QI�TRICT <br /> (COMPLETE IN TRIPLICATWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 7 2 and the rules and regulations of the San Jo quin Local Hea tl�District. <br /> Exact Site Address .— �� � City/Town � 4P— /W A' s <br /> Owner's Name 4 r ' Phone <br /> Address City ^•' <br /> / i # <br /> r. License Business Phone 7 YS' 3 �f 7 <br /> Contractor's Names < `•�` d" � <br /> Contractor's Addr c t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Com` DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 �— <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines S i Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line7 � Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> C3 INDUSTRIAL ®"`CABLE TOOL Dia. of Well Excavation <br /> R" 0MESTIC/PRIVATE C1 DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ®'IRRIGATION 13GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surf Seat Inst [led By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State 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 <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: <br /> Date: � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY C� �1 <br /> PHASE 1 A <br /> � ._ IrM ©i Date i. "a`' <br /> Application Accepted By •,' <br /> Additional Comments: <br /> ase tl Grout In tjan Ph 5e it Fina! inspection <br /> inspection By Daae !?— 1 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedBy July 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 67-k_) 9 2 <br /> Received by Date Receipt No, Permit No <br /> I uanc Date Mailed Delivered <br /> ERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITlS <br />