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Applications Will Be Processed When Submitted Properly Completed. Be Sur ign The Application. <br /> FOR-OFFICE USE: APPLICATION MAR 26 1981 <br /> Ile- (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAM JOt'QUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTINCT <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 /> r <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sa Joaquin Local Health District. <br /> If 0 el <br /> Exact Site Address 10 7 g �}}`F VVU 4 � QC) City/Town es� --' <br /> 7. A r4 J a� —729a ' <br /> Owner's Name Phone . <br /> Address G�',r,: City— - - p— %7 ,! <br /> Contractor's Name , License# .2� I� ' Business Phone�muy,/ , <br /> Contractor's Address Emergency Phohe « , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No <br /> TYPE OF WORK-(CHECK): NEW'WELL El _ DEEPEN ElRECONDITION❑ DESTRUCTION❑ - - - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ T I <br /> REPLACEMENT IQ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_- Pit Priv <br /> yF Y <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 TOOL Dia. of Well Excavation <br /> • a <br /> KDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C <br /> ❑ IRRIGATION r ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: k <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: State Work Done -T <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 4__ <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ~J <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 r a Grout Inspe n rto grouting and a final inspection. ' <br /> Signed X Title: Date: <br /> 00, (Draw Plot Plan on Re rse Side) :4 , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE . <br /> Application Acceptery <br /> d By -- Dated <br /> Additional Comments: <br /> .Phase II Grout Inspection as I Final Inspectio <br /> Inspection By Cl^ in Date Inspection By Date <br /> F <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 &R ved By January 31 ' ' ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE c; O `>3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> fn <br /> Received by bale t Receipt No. - Permit No, Issuance Date- Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2004 STOCKTON,CA 95201 <br />