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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: � „� <br /> irc_7z�.' ,PLICATION <br /> ' (For Non=Transferable,'Revocable, Suspendable) <br /> TAL HEALTH PERMIT ( PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) Lj� Kn`lC WA ER 411A�tTY Application is hereby made to#heSan Joaquin Lo I Wealth Distri a permit to construct and!orinstall the work here described.This application is <br /> !'j.;-made in compliance with San Joaq County O di fn/No. 1862 and the rul s an regulations of the San J again Local Health District. <br /> i Exact Site Address <br /> Mcity/Town <br /> -'`sAwner's Name <br /> Address Phone �r <br /> Contractor's Name City-- <br /> License <br /> �� License i3 ingss hone l I <br /> Contractor's Address - <br /> Is Certificate of Workman's Compensation Insurance on 'IT 46 <br /> File With SJLHD?ergYesy phone <br /> 4L_ <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL B__DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION*` PUMP REPAIR IJ <br /> DISTANCE TO NEAREST: Septic Tank I <br /> ewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> , , Other" Pro ortY Line Private Domestic Well <br /> Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ I USTRIAL ❑ CABLE TOOL • <br /> Dia, of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC Dia. o of C Casing <br /> i [��' ❑'DRIVEN Gauge of Casing <br /> RLA— <br /> RIGATION ❑ GR VEL PACK <br /> © CATHODIC PROTECTION Depth of Grout Seal <br /> ❑ DISPOSAL RY Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t. s <br /> PUMP INSTALLATION: r u ace Sea: stalled <br /> Contractor <br /> Type of"pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ' ' 1 d <br /> PUMP REPAIR: ❑ State W,�ck3Do�le <br /> DESTRUCTION OF WELL: ' u y <br /> Well [7jamete <br /> r -- �. :,,- - .� { <br /> Approximate Depth R" <br /> Descrfb$.Materlal and Procedure'' , <br /> I hereby certify that I have prepared thls`apptica{ron'ind that:the Work wltl"be done in accdrdance wlth...5an 7oagt,ln County <br /> ordinances, state laws, and rules and regelJafions of6h6�%r6oaqurn Locaf`,Health District . �t <br /> Home owner or licensed agent's sign atur;411'rtiflei#a followAI "1 certify that in the perforrrtance of the vyoi k€or which this permitk <br /> * is issued, I shall not employ any person much:manner as to become subject to workman s`compenstion fa+nrs`of California." <br /> Contractor's hiring arsub-contracting signature certifiesfKe following:'f'certify that in the performance o Fhe,work�for which this <br /> Permit is issued, I shall employ <br /> p - persons subject to workman's coIftipensation laws of California." <br /> I will c for rout Inspection'prior toAro and a final inspection. -Y • '' i <br /> Signed X <br /> "Title: Dale: 0001 <br /> a..� <br /> (Draw Plot Plan on Reverse side) <br /> FOR DEPARTMENT USE ONLY y <br /> PHASE <br /> Application Accepted By1 <br /> Additional Comments: Date <br /> Phase II Grout inspection .•- y y <br /> Inspection ByPhase III Final Inspection <br /> Date rnspectiari-By-, Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE { <br /> ❑ EACH ❑ January T&'Receive y an -'ry'3T' r_1 1 &Received By July 31 <br /> f <br /> BASE EXPLANATION BILLING REMITTANCE - § +, REMIT <br /> 1 GATE DATE ';.TREMI ED AMOUNT DUE .`.,CHECKED _ <br /> FEE <br /> ".,AMOUNT r' <br /> LESS <br /> PRORATION <br /> PLUSN /Gb7l /rG7-G q (!`/ 4x � ��Gt <br /> PENALTY e/ /�" _ l(•�/i�j `�! ["c' Lar'7'�� 4 / <br /> � OCHER <br /> OTHER ..x„ <br /> rte, r <br /> Received by + Date �'Recer t No. <br /> P Permit No. Iss ante ate Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERM ITlSERVICESDelivered ;y.: . <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.ce GKIM ' <br />