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FOR OFFICE USE: MAY u Z) tabu APPLICATION <br /> ForTransferable, Revocable,Suspendabl( <br /> SAN JO. ,- L81FAL `% PUMP&WELL <br /> HEALTH DI"MPNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> made in compliance withan Jqaq Count rdinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address H)�lV � g CitylfownAz <br /> f�-:�n <br /> Owner's Name Phone, ^ ,S%- p� <br /> Address Cityf'P C� <br /> Contractor's Name �e it-t-Iler JIUAl S License# e,,7 09Z Business Phone goo _3— iew_/1� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDI Yes No <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 <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 //jj pp Sujface/Seal Installed By: Q <br /> PUMP INSTALLATION: Contractor 1T f 17 le/Cor, C_ <br /> Type of Pump H P. <br /> PUMP REPLACEMENT: ❑ State Work Done N <br /> PUMP REPAIR: 0 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 A <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 sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California" <br /> 1 will es for/j Gr spection prior to grouting and a final Inspection <br /> Signed X ft� +F . �.,o,pJ�— Title: / Date: <br /> (Draw Plot Plan on Reverse ide) <br /> FO EPA MENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 R v By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> c yd9 [ AMOUNT <br /> �t <br /> FEE `� qv rrr �v <br /> LESS l <br /> PRORATION <br /> PLUS 2U <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �S 9z?:0 33 O <br /> Received by Date Receipt No. Permit No. Issuance Date Malled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />