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g <br /> ` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> T FstWJ?F fCE USE: APPLICATION <br /> j MR <br /> (For Non-Transfera a L, sge bl PUMP&WELL <br /> ENVIRONMEN F EA �PERI� <br /> ('COMPLETE IN TRIPLICATE) WA UAWAR,-1 p; i�nn <br /> Application is hereby made to the San Joaquin Local Health District fora permit to constru and r n tall the work herein described.This application is <br /> made in compliance with San Joag uin Count OrN <br /> I�dinance o. 1862 and the r I a 6 e%j y I f h San a uin Local Health District. <br /> Exact Site Address_f 70.3 �ii9{d.yY� S � n i <br /> Owner's Name Phone O } lwort <br /> Address j — u—. — � tJ City _ <br /> Contractor's Name License ft zBusiness Phone'�4K_ �S t <br /> Contractor's Address f' 0. Z - Emergency Phone W <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ --� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0'�^ 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 1 TYPE OF WELL <br /> ' LJINDUSTRIAL ❑'CABLLE TOO --- � —Dia-of Weil 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 /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: Mate Work Done <br /> PUMP REPAIR: State Work Dene oz <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Material and Procedure . <br /> I 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 /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r <br /> f 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 /> I will callfora,Grout Inspection prior to grouting <br /> and a final inspection. <br /> Signed X _ U�-�2N� �I?. /,�_ {J-� G4 ([ffi] zffitle: Date: 7- <br /> an <br /> an on Reverse Sides <br /> 01 DEPA�TMENSE,ONLY <br /> PHASE I _0 Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection hase 111 Final Ins eclion <br /> Inspection By Date Inspection Bye r Date ,3- _F� <br /> � Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ff-ILR StTE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> 4 BILLING REMITTANCE - <br /> BASE EXPLANAT ON DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ( ✓ I ✓1 '� .� <br /> LESS <br /> PRORATION <br /> PLUS 1'011,..°s I"uw 4 f <br /> PENALTY <br /> OTHER I :I �• U � 'L <br /> OTHER <br /> Received by Date { Receipt No. Permit No. I suan a 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 />