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Applications Will Be Processed When Submitted Properly L.omplelea 0%:M31V L.L2d <br /> FOR OFFICE USE: APPLICATION MAR 19 1981 <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN Lvr`AL <br /> A ER QUALITY HEALTH DISTMCT2la(_ Z��/-� z_ <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permltto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinan No.1,§62 and the rules and regulations of the San aquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone — 2 <br /> Owner's 579 <br /> Nam OLi <br /> Address City _ <br /> Contractor's Name * License#�,O 0� Business PhoneContractor's Address Address Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes�� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR©� <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 '1 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing [n <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 Surface Seal installed By: —� <br /> PUMP INSTALLATION: Contractor gvA� H.P. <br /> +� <br /> Type of Pump T �t <br /> PUMP REPLACEMENT: ❑ State Work Done � A <br /> Work D <br /> State Worone- <br /> PUMP REPAIR: 7� <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 Cil <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 ofthe 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 will cap for a Grout In ecti glor to grouting and a final inspe n. f� <br /> Signed X <br /> Title: -v ^�-'�� Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE 1 C46 t <br /> Application Accepted By i�••.- Date <br /> Additional Comments: <br /> Phase It Grout Inspection h se 111 Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �� � <br />