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Applications Will Be Processed When Submitted Properly Completq ell!f-er47 PSI T" lir?a i <br /> FOR OFFICE USE: APPLICATION 5 t ilj I� <br /> (For Non-Transferable, Revocable, Sus ��able) <br /> ENVIRONMENTAL HEALTH PaMITMAR 12 1981 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY y. t 1 `�{, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/& atNl�fh'Afv�4iork( 1 r f{i Scrlbed.Thisapplicationis <br /> made in compliance with San Joa . County Or finance NO 1862 and the rules and regulations FtfQ-Tari JW4i l�Local Health District. <br /> Exact Site Address .2/f�74 i13iQ City/Town S <br /> Owner's Name t7 f..t Phone .._� <br /> Address ( 1Ak City <br /> Contractor's Name �'1 EIZ 1 AJ �g(�, License#3�57 YZ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X - No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR V <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 /> ❑lDOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> OIRRIGATION ❑ 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 �}'IYt-t2,�1~,tc R1 +tion <br /> Type of Pump —rLyNo%-7— _ H.P. d <br /> PUMP REPLACEMENT: ❑ State Work Done - v <br /> PUMP REPAIR: ❑ State Work Done - <br /> v <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 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 /> 'II will call for a Grout 1 spection prior to grouting and a final Inspection. r� <br /> Signed X t*7r 1 - _ Title: ?,ew,�40 �4AZI,' Date: <br /> ^ ;J (Draw Plot Plan on Reverse Side) 41 <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI / <br /> Application Accepted By �O Date ��� <br /> Additional Comments: <br /> Phase 11 Grout Inspection hale III Final Inspection <br /> Inspection By Date Inspectio Date !� ���_ <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE C] EACH El January Received By January 31 ❑ July 1 &Received 8y July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMIJ-TED AMOUNT <br /> FEE <br /> FZk <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 /v Z71 6 5 /,,j ! 8` <br /> Received by I Datd 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 2009 STOCKTON,C <br />