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Applications Will Be Processed When Submitted Properly Completed. BJW#eJA"n-TheApplication. <br /> FOR OFFICE USE: 23 i9(9 <br /> APPLICATION �'� — <br /> (For Non-Transferable, Revocable,Suspends e) AUG PUMP&WELLENVIRONMENTAL HEALTH PERMITS LOCAL <br /> SAN JC)AQU� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �j;ALTH IN <br /> Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconstructand/orinstallt ework herein described.This application is <br /> made in compliance with San�Joagttin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4(/e City/Town <br /> r <br /> Owner's Name Phone <br /> Address 111 40_� 0—/ OR 7 City "� "J <br /> Contractor's Name , J cJ 7iG? Sn A) _ License# ' 1?0 f-C> Business Phone B S19' <br /> 02 <br /> Contractor's Address �'r` Z At A�►� Emergency Phone <br /> � \ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesJ� No ` <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ O <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 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 {� �/ urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. % Soni' <br /> Type of Pump 54 H.P. Q� <br /> PUMP REPLACEMENT: ❑ State Work Done {' <br /> PUMP REPAIR: ❑ State Work Done .� <br /> mate Depth <br /> A <br /> DESTRUCTION OF WELL: Well Diameter Approximate <br /> I Describe Material and Procedure <br />�I <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 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> j 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 c for a Grout Insp ion p for to grouting and a final inspe 'on. <br /> Signed X Title: Date: F <br /> {Draw Plot Plan on Reverse Side) <br /> F R DEPA NT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspections 'P s III Final nspection � � <br /> Inspection By Date Inspection Byl/ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �� Gj�1 c� <br /> �FEE�S <br /> PRORATION <br /> PLUS <br /> _. PENALTY <br /> i OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mailed - Delivered <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />