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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The�►1�cation. LLJJ <br /> FOR OFFICE USE: v APPLICATION E FEB 221983 <br /> (For Nan-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT SAN OAQUIN LOCAL <br /> WATER QUALITY, ,. MEAL!� DISTRICT <br /> (COMPLETE IN TRIPLICATE) <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 San Jo a um County Ordin nce No. 1862 and the rules7d regulations„of.the San Joaquin Local H alth District. <br /> Exact Site Address L x G10,m City/Town <br /> Owner's Nam' <br /> R. 7L1/_” •` h L xr -x Phone 3-7 �� SCI <br /> Address es N. GL.t� ycity,., G. ._ <br /> Contractor's Name ;'k• .Sc,� Licerl'se# AOs� " Bu•siness Phone', 3 j" �`��' -7 I <br /> _ .-Ph !�! <br /> Contractor's Address i.✓ Emergencyon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - ' No <br /> TYPE OF WORK (CHECK): NEW WELL❑'r DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ElWELL ABANDONMENT ❑ OTHER E] PUMP INSTALLATION❑ PUMP REPAIRI� III <br /> 9 <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 /> INTENDED USE TYPE OF WELL �± <br /> ❑ INDUSTRIAL ❑ CABLE TO Dia. of Well Excavation <br /> 90 DOMESTIC/PRIVATE 13 DRILLED ° Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION L ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor N.. <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: [],State Work Done <br /> PUMP REPAIR: 19 State Work Done 9L <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> - I Ica fora rout spection prior to grouting and a final inspection. <br /> Signed X:— ; Title: V ..Date: <br /> s (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT SE ONLY <br /> PHASE I s <br /> _ Date -LB� <br /> Application Accepted B I <br /> Additional Commen <br /> Phase II Grout Inspection P ase III Final Inspection <br /> } Inspection By Date 4 Inspection By .ter Date <br /> c <br /> ' Fee Is Due: ❑ ANNUALLY [].PER UNIT ❑ 'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 C I <br /> REMIT <br /> BASE, EXPLANATION BILLING { REMITTANCE '- $ s AMOUNT DUE CHECKED <br /> DATAMOUNT <br /> E DATE REMITTED <br /> FEE S a <br /> j LESS. <br /> PRORATION <br /> PLUS <br /> PENALTY' _ <br /> OTHER <br /> OTHER - <br /> E T <br /> Received yate k Receipt No: Permit No. Is uance ate- - Mailed De1iveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 r <br />