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FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, <br /> ENVIRONMENTAL FiEA \, ((�A\F�%)�) PUMP 84WELL <br /> \.� <br /> (COMPLETE IN TRIPLICATE) WASrr�ry��RR 4 Y <br /> Application is hereby madetothe San Joaquin Local Health District ±- constr t'f2lr install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 186 he rule �tlo 1ulation}s�yf-py�San J aquin Local Health District. <br /> Exact Site Address t C }'v�„R°n � � <br /> Owner's Name n0.Ci \Sphone 9,046 - I6 <br /> Address IT CR S , 11 City <br /> Contractor's Name License if �, 2-3 Business Phone <br /> Contractor's Address �'- n� Emergency Phone C <br /> Is Certificate of Workman's Compensation I surance on File With SJLHD? Yes °� No l <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION ,,,// <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION PUMP R AIR LJ <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: [7f 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 /> 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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call forr�aa Grout InspectioQn prior to grouting and a final inspection. r� �1 <br /> Signed X &g&k I� �'cW C. f ni .an..e� / Title: � fj�'tQ f+-�� Date:X 41 d <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP TMENT USE ONLY <br /> PHASEI <br /> Application Accepted By `— Q Date a2 eO <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By — Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> A _NT <br /> FEE co Cl cocl <br /> LESS y T J <br /> PRORATION —p D <br /> PLUS <br /> PENALTY 'S <br /> OTHER �L <br /> OTHER <br /> 67,sie,c, J6G <br /> Received by 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 20M STOCKTON,CA 95201 <br />