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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> i� (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY_ <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made-in compliance with San Joaquin County Ordi�na%ice 7N . 1862 and t r les and regulations of the San.Joaquin Local Health District. <br /> Exact Site Address S t!, A City/Town %z c1= /u <br /> Owner's Name = Phone 47 <br /> - <br /> AddressCity_ a;c� <br /> Contractor's Name � ''• License#,7.?,j1Z!1 Business Phone��- <br /> � z <br /> Contractor's Address C "Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ.LHD? Yes-Y' C No <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑, OTHER ❑ PUMP INSTALLATION ❑ - PUMP REPAIR ' <br /> REPLACEMENT❑ r ( . <br /> DISTANCE TO NEAREST: Septic Tank .2 C Sewer Lines �b Pit Privy <br /> Sewage Disposal Field /DC) "f Cesspool/�eepage Pit Other <br /> Property Line/4Q 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 i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN "" Gauge of Casing 9 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 111 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout w+ a^1 -- <br /> ❑ DISPOSAL ❑ OTHER Other Information _"� y <br /> 11 GEOPHYSICAL -Surface Seal installed By: —�9j �� F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: n Well Diameter r 1 Approximate Depth <br /> Describe Material and Procedure- <br /> . � <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." I <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 perso s Subject to workman's compensation laws of California." r' <br /> I will call for a G ut In ctio r to grouting and a final inspection. .= - <br /> i <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Rever Side) i <br /> i T FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' Application Accepted y - Date <br /> Additional Commen <br /> qq � /6. <br /> hate II Grout Inspection ? r�1�z' � k I uti%rtGf�e'o1u 7/i 1/'i Phase III Final Inspection <br /> Inspection By Date^ Z.�-•- Inspection By Date""( <br /> Fee Is Due: ❑ ANNUALLY� ❑ PER UNIT S' '❑ PER SITE'_ ❑ EACH '❑ January V&Received'By January 31 ❑ July 1 &Rkeived ByJuly31 , <br /> REMIT <br /> 1 ,BILLING- � REMITTANCE $ <br /> BASE EXPLANATION- AMOUNT DUE CHECKED } <br /> DATE DATE- REMITTED AMOUNT <br /> t FEE 3 _ <br /> LESS .. �.. -71 <br /> 7 � <br /> PRORATION <br /> PLUS 0 <br /> PENALTY 1 <br /> OTHER $h^M✓ ( C.G>I JJ� <br /> Vkv v <br /> OTHER <br /> v — <br /> Y sBs3 " Z <br /> "?Received by - -Date—a Receipt No. - PermitNo. v„� - Iss ante r5ate Mailed - Delivered-- - i <br /> APPLICANT--RETURN ALL COPIES TO: ''ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009. STOCKTON,CA 9520' <br />