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Appk.*6 is WIL P en`b llmitted Properly Completed.Be Sure To Sign The Appllcafion:""� <br /> � <br /> l ' FOR OftlC -USE: fillAY I I" APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendable) j f <br /> - SAN JOAQUIN LOCAL PUMP&WELL � <br /> HEALTH DISMMNMENTAL 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 with an JoaqLjA Courlty Qrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District.: <br /> Exact Site Address p� } - City/Town -_Z* G 1 <br /> Owner's Name Phone- �^ . <br /> Address City <br /> Contractor's Name f /'i i SXA,9 License# ,Z961-40lBusiness Phone <br /> Contractor's Address Emergency Phone <br /> :1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 13 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 Prlvate Domestic Well Public Domestic Well <br /> INTENDED USE t TYPE OF WELL 1 <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 t ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information_ I <br /> ❑ GEOPHYSICAL (f surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor In'- riC, , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Donee <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 Sad-Joaquin Local Health District- <br /> nr <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof 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-conUacting.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 ca for Gro action.prior to grouting and a final inspection <br /> Signed X • —%� �-- Title: Date: <br /> g � ._._ (Draw Plot.Plan o_n Revers--etide)' T� <br /> - FO EPA ENT U _`QNLY� - <br /> PHASEI r <br /> Application Accepted By Date <br /> Additional Comments: 111 <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 t S Re ive By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED } <br /> DATE DATE REMITTED AMOUNT 7 <br /> - - �S <br /> .. FEE `� <br /> LESS <br /> PRORATION <br /> / 1 <br /> PLUS r 2 <br /> PENALTY (J <br /> OTHER _ <br /> OTHER - - - <br /> �S .« `L'?o 1 . 33 7%S 1 s Vic} <br /> a <br /> Received by Dale Receipt No. -Permit No. Issuance Date Mailed Delivered <br /> �� APPLICANT—RETURN ALL COPIES TO: x ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 - •f <br />