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Applications Will Be Processed When Submitted Properly Completed. Beu. Tp=$iT icatlon. <br /> FOR OFFICE USE: APPLICATION <br /> t- <br /> (For Non-Transferable, Re HEAL <br /> ulq <br /> 4> ENVIRONMENTAL HEAL ERM 19a1 PUMP&WELL I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY •� SPL /�-f <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstruct and/or trlstr 1t� describe .This application is <br /> made in compliance wit �loaquin n y r i an o.�2 and the rule nd r ut�i s d S � i oc Ith Di District- <br /> Exact <br /> j <br /> Exact Site Address / / d� � wn i <br /> Owner's Name �`f�Z Phone <br /> Address � �� City. -_ � ^� _ <br /> Contractor's Name .. License# .� Busine .Phone C <br /> _ LC"� S <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 7 � No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 1:1RECONDITION 11DESTRUCTION❑ 4 <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 Weil <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 Surface Seal Installed By: <br /> PUMP INSTALLATION! Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: ✓ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> Describe Material and Procedure <br /> i <br /> - t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. + <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> is issued, I shall no mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contr g or sub-contracting signature certifies the following:"I y that in the performance of the work for which this <br /> per it is I shall emp y per ns subject to workman's cot, nsa ' n laws of California." x <br /> I ill In ion p ' r to ro 'ting and a final inspe�� <br /> Signed <br /> n. <br /> Signed X _ Till _. _ Date: <br /> (Draw Plot Plan n Reverse Side) <br /> s <br /> R FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By � � 1 _ _ Date <br /> Additional Comments: <br /> P e II Grout Inspection se III F" al Inspection <br /> Inspection By Date _ Inspection By � Date - -7— <br /> Fee Is Due: ❑ ANNUALI Y ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ ,anuary' &Received By Janaary 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BILLING REMITIANGE b <br /> BASE EXPLANA—ION DATE DA—E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT f <br /> FEE / .-14 S <br /> �— <br /> ESS ) <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 01 HER <br /> OTHER <br /> Recurved by Date Receipt No 1ttPermit No. I a(no)eW�281et Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />