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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Atation, <br /> i <br /> FOR OFFICE USE: APPLICATION FEB 221983 <br /> ' (For Non-Transferable, Revocable;Suspendab le) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT s !,,.) sQu!m LOCAL <br /> (COMPLETE IN TRIPLICATE) _.WATER QUALITY,,...,. , ,. ..t^ HEALI H DISTMT, <br /> Application is hereby made to the San Joaquin Local Health Districttorapermit.toconstruct and/or install the work herein described.This application is <br /> v. <br /> made in compliance with San Joaquin C unty Ordinance No. 1862 and the rulf regulations-of the Sany�oaquin Local Health District.. <br /> Exact Site Address v- City/Town [ <br /> Owner's'Name "� E3 V � C+ ZL 1.1 Phone_ + <br /> Address lel r>ji s ':3 1� V .; City 1 <br /> Contractor's Name i caU '-_°License# _ Business Phone <br /> Contractor's Address . -`�YJ101), Emergency Phone <br /> EIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No l <br /> TYPE OF WORK (CHECk): NEW WELL ' DEEPEN ❑ ' `RECONDITION❑ DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pitt Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> I INTENDED USE 1 TYPE OF WELL <br /> ❑ INDUSTRIAL— ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC f ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK -Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information -� <br /> ❑ GEOPHYSICAL 4 Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .� <br /> PUMP REPLACEMENT:- State Work-Done= <br /> PUMP REPAIR: ® State Work Done ,►R, PiakkA, fb <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:"1 certify that in the performance of the work forwhich 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 vrWcall for a Grout spec n prior to grouting and a final inspection. <br /> Signed X Title: 'Date, J <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted 8y r �e_�ffi Date <br /> Additional Comments- <br /> hase ll PLOW Inspection s III Final Inspection !1 <br /> Inspection By Date Inspection By Date � cz <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT; J-❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> ' <br /> BASE EXPLANATION BILLING REMITTANCF $ AMOUNT DUE CHECKED <br /> [I DATE DATE M.REMITTED AMOUNT <br /> f FEE .- <br /> LESS <br /> PRORATION i <br /> PLUS { �. <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No:` Permit No. fill I uanee Date- Mailed– Delii/ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E-HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA.9S201 <br />