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l` Applications Will Be Processed When Submitted ProperIpl�en�,ee@ sure ,q <br /> APPLI L� <br /> iWOR OFfICE.USr:... O <br /> (For Non-Transferabl lItt o Ale, Suspendat* <br /> PUMP&WELL / <br /> ENVIRONMENTA ALj}LI,�E�MIT �C�AU <br /> WATER QUALITY c+11���U A \G� <br /> (COMPLETE IN TRIPLICATE) '�FQ. R <br /> Application is hereby made to theSan Joaquin Local Health Distdctfor e ermittoc ��Q�fj,,'Qt�°°r Ithework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules tafions of the San Joaquin Local Health District. <br /> Exact Site Address S 32 City/Town J:on b — <br /> Owner's Name Phone O,.�N s6 0 <br /> Address —T ,?—�►}' 1 I2.1 city :g? <br /> Contractor's Namei(.r—i �� License If Business Phone <br /> Contractor's Addressgid'lit—� -2 Emergency Phone ^� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No d <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑O I <br /> WELL CHLORIN13WELL ABANDONMENT 11OTHER 13 PUMP INSTALLATION L PUMP REPAIR❑ <br /> REPLACEMENT IS�d <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy CIS <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 /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dla.of Well Casing .. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> F ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ~ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 1 PUMP INSTALLATION: Contractor <br /> _ Type of Pump H.P. <br /> 9 PUMP REPLACEMENT: iffState Work Done <br /> PUMP REPAIR: ❑ 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 t <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t I will call for a Grout Inspection prior to grouting and a final Inspection. ¢� <br /> Signed X I1 .fig A —nt f �t.._w /1Title: - Dater=/�-- <br /> (Draw blot Plan on Reverse Side) _ <br /> —r <br /> ' �pFOR DEPARTMENT USE ONLY - - <br /> M PHASE I \111._ - GALO� © Date <br /> g D-' <br /> I! Application Accepted By <br /> t <br /> t Additional Comments: �. <br /> Phase II Grout Impectbri Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By IW Date Z'J�_ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received Byl July 31 <br /> e BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` BASE EXPLANATION DATE DATE REMITTED 4 tl AMOUNT <br /> N �a FEE 4 <br /> LESS' <br /> i PRORATION <br /> PLUS <br /> I PENALTY <br /> I OTHER ' <br /> OTHER <br /> Receipt No. Permit No. 'lea arca to �Melled - Delivered < /' <br /> Received by 09M. I..sea P.am 2009- STOCKTON.OA 95201 '� <br />