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AAppl _ n Ade�s1d lAe � mitted Properly Completed.Be Sure To Sign The Application. , <br /> V' FOR OFFICE USE: PPLICATION <br /> AUG — 2 1@Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN .,OAt UIN LOCAL WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) { p j� !! I T <br /> Application is hereby made to the S� AQ11 AaHe istrict for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with n Joaquin County Ordinance No.L162 and the rules and regulations of the San uln cat Health District. <br /> Exact Site Address 6 �' � "'""'r"3' City/Town <br /> Owner's Name fl,` Phone ? 3 <br /> Address ' --a city�� <br /> Contractor's Name License# 373 Business Phone '5�'6!2 �— 9 <br /> Contractor's Address c� Emergency Phone z71 (�,"g � Z X__ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L-1-1 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL�'� f,t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy /n <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther Property Line Private Domestic Well Public Domestic Well <br /> INTENDED 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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL [(' �7Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,Zt Es H.P. - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 'h <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 w'I�rat pection prior to grouting and asfinal ingm tion. <br /> Signed X Ale: Date: (' <br /> (Draw Plot Pian on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � (2)j_o1,—�o�. <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase,111 Final Inspection <br /> Inspection By Date Inspection By Date i- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 0 � C� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y <br /> Received by Date Receipt No. Permit No. I ssfiancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952dT <br />