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_ 7 Applications Will Be Processed When Submitted Property Completed.Be SureTo51gn Iner.PP11' <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Tran;ferabte, F�evocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY ,. �,.. <br /> his a <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local aencehNo 1862 ar dphe rules and'regulatons oftthe San o oa uinl Local HealthTDistrict. ation is <br /> made in compliance with Sar Joaquin County O ,� �. IL City/Town 0 <br /> Exact Site Address t 3 �" <br /> b AL f I ,ri Phone' , <br /> Owner's Name# �" � �.T; <br /> QAIJ 4 City I <br /> Address <br /> '� t? t'Llcertse# Business Phoner <br /> Contractor's Name E' Emergency Phone" <br /> Contractor's Address 1�� No _ <br /> Is Certificate of Workman's Compensation In on File With SJLHD? Yes _ _ <br /> TYPE OF WORK (CHECK):A—NEW WELL -_ DEEPEN ❑ RECONDITION iTl PUMP INSTALLATION ❑ PUMP REPAIR❑ r,,A I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> REPLACEMENT❑ t� <br /> Sewer Lines <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank —1 : rw 3=•� Other— <br /> =ei 4poo.I/Seepa9,PAt. .�M ,. ... - <br /> ••,,,,,"�,,,,.-_ __„•.,�.,-.T,......,,_...:....Sewage•-Dispesal-Field-�------•----•--W----"^`" Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USS <br /> TYPE OF WELL ��K <br /> 13 INDUSTRIAL CABLE TOOL Dia. of Well Excavation ,y <br /> El DRILLED Dia. of Well Casing <br /> C1DOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUiSLIG­T" ❑ DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION # i ;yj ,. Type of Grout <br /> k ❑ CATHODIC PROTECTION 't '^�❑ ROTARY <br /> 13 DISPOSAL <br /> El OTHER Other Information <br /> Surface Seal Installed By: <br /> 0 GEOPHYSICALa <br /> PUMP 1f15TALLAT N�. .•�.'- :�".:""""Ganttactors •-� 9 g . <br /> H.P. <br /> Type of Pump <br /> i <br /> [3# State Work Done <br /> PUMP REPLACEMENT:.-.---• � � I <br /> PUMP REPAIR:, O'State'Worh Done 3 <br /> t 'V11 Il• Iometer Approximate Depth <br /> e. > <br /> DESTRUCTION-00 WELL: � � ,:� �.,p e:— <br /> r <br /> -Describe Material and Procedure ! W <br /> 1 herifb certify°that I have prepared this application and that the work will be done'in accordance with Sian Joaquin County 1 <br /> ordin noes, sate laws, and rules and regulations of the San Joaquin Local Health District, <br /> V1 <br /> j Home.oinner ar,licensed.agent�signature certifies the following:"1 certify that inthe performance of the work for which this permit <br /> °"`` A' ' erson in such manner as to become subject to workman's compensation laws of California." <br /> is i v ed, I shall not employ'a�1y p <br /> C rjt dors or sub signature certifies the following:"I certify that in the performance#f the wDrk forwhich this <br /> r p m i� iss gid, I all empl person subject to workman's compensation laws of California. <br /> I }w call fo Gro In i n;prior o grouting and a final ins ection�— 2 <br /> r Date <br /> Title: <br /> : <br /> . ,,, .• °. _ � , <br /> Signed X �. " raw-Plot Plan on Reverse Side) i <br /> S FOR DEPARTMENT USE ONLY <br /> r PHASE I ( .. 1C�� l.� s%iDats—�=—u <br /> [< <br /> Application Accepted By % ?'14J""" f <br /> Additional Cbmments: <br /> Phi - <br /> altnspeciion <br /> Phase 11 Grout Inspection , " "- <br /> i j Inspection By Date <br /> Inspection By _ _ Date � <br /> R-U[VIT" •PER SITE ❑ EiP.CH 0 Jan aryp.� wed By'�fanuary 3Y� July t S Received By July 31 - <br /> Fee Is Due: ANNUALLY ❑ PP y -.ate REMIT <br /> *s. - F"` ' �t.?�ra.:�.`'+>�,!]te• a.1�. F t�Re� f�DP.7 � „�y .- r <br /> CHECKED <br /> BILLING REMITTED AMOUNTDUE' AMOUNT <br /> BASE . �NATIO <br /> AT <br /> FEE <br /> a <br /> ...LESS <br /> PRORATION~ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t OTHER V 7 - <br /> Date. Receipt No. <br /> Permit No.- .v .- - ssuance Dat _Mailed. .Delivered` - <br /> Received by -- - ' � 1801 E.HAZELTON AVE.,P.O.13oK 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5 - _ <br />