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Applications Will be Processed When Submitted Properly Completed.`se.'Spr4e'..�'F&_8ign T 1,99.1 tion. <br /> FOR OFFICE USE: APPLICATION�� 2 <br /> (For Non-Transferable, Revocable, uf: endable) PU WELL <br /> ' IJENVIRONMENTAL HEALTH ERMhOV S 1982 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �? <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct,%Wgriei(tali9gg?e"Wdrk el Lescribed.Thisapplicationis <br /> P q Y gW AJ <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and re ula I p ocal Health District. <br /> Exact Site Address Z e) -� City/Town '7 - <br /> Owner's Name IG/�U�rC �av,/�`._ -_ Phone ! -- 5-- C77 11"i <br /> Address 1 r 6 5o F <br /> City-- ,= 1A <br /> _ Contractor's Name License# / 9273 Business Phone rf 6� 2695 A <br /> S <br /> Contractor's Address 6'_s 6?! L'; 7 Z,0_ 5'Syi 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 CHLORINAT C3 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT <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 /> INTEN6ED 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 I) <br /> ❑ IRRIGATION ❑ GRAVES_ PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13 ROTARY Type of Grout Q <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL % Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. U <br /> PUMP REPLACEMENT: 9—State Work Done ,z/.r a0d L�" <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 /> 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 <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 ep _ Title: � Date: V-Z-9 <br /> (Draw Plot Plan on Reverse Ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application iion Accepted By '" "" "" - Date <br /> Additional Comments: 4 <br /> Phase li Grout Inspection Phase E Final Inspection <br /> Inspection By Date Inspection By Date 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 5 <br /> LESS [ �Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a ­.-_ i�l -�8- S.3 Zy 4M me_—S q LA <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />