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App�l(cations V1)fill BP� ed When Submitted <br /> APPLICATION <br /> FOR OFFICE USE: n-Transterable, Revocable, 5uspendable) PUMP &WELL <br /> w ® DENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY lithe work <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSan Joaquin Local Health Districttoraperm <br /> rutles and r gulatioons of the San Joaquin lLo al HeathTDistricthis . anon Is <br /> r insta <br /> a <br /> made in compliance with San Joaquin COuntygo lOrdinance . 1862and � Ll i� �� City/Town 6. <br /> i Exact Site Address Phone101111 i <br /> Owner's Name , 40 City ygrQ�� <br /> Address Z Business Phone <br /> -- License#c3Sn s 1 .. <br /> Contractor's Name 11 EmergencyPh net <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑ �, <br /> (, TYPE OF WORT( (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION DESTRUCTION <br /> ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I6 PUMP REPAIR <br /> WELL CHLORINATION _ <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic-Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line i <br /> Private Domestic Weil "�- <br /> C <br /> TYPE OF WELL <br /> i INTENDED USE pia, of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL. <br /> � ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PRIVATE 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other information <br /> ❑ DISPOSAL rface Seal Installed By: C <br /> ❑ GEOPHYSICAL to, C <br /> t Contractor H.P. <br /> F PUMP INSTALLATION: <br /> . Type of Pump <br /> ❑ State Work DoneA.) _ <br /> PUMP REPLACEMENT: Get <br /> SL5tate•Work Done � Approximate Depth <br /> PUMP REPAIR:- " - Well Diameter <br /> r DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> f. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> uin Local <br /> ordinances, state laws, and rules and reg elect lies the tollowin ions of the Sanoaq certify than n tlhe performance of the work for which th District. this permit <br /> F g;,. <br /> - Home owner or licensed agent's signature <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation caws of California. <br /> Contractor's hiring or sub-contracting ng:"1 certify that in the performance pi the work for which this <br /> signature certifies the following: <br /> ns subject to workman's compensation laws of California." <br /> permit is is ued, I shall employ <br /> 1 I al a Gro t pe an r to grouting and a final inspection. I T <br /> I <br /> Date: <br /> Title:. <br /> ice.,_ Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - <br /> - <br /> PHASE 1 � .Date <br /> , <br /> Application Accepted By <br /> Additional Comments: ph e I I Final Inspection <br /> Phase 11 Grout Inspection inspection By ` Date c::\ <br /> � <br /> Inspection By pate <br /> PER UNIT ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 <br /> ❑ July 1 &Received By July 3i <br /> REMIT <br /> Fee IS Dile: ❑ ANNUALLY ❑ CHECKED <br /> BILLING REMITTANCE $� AMOUNT DUE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> k FEE a <br /> i LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> y <br /> OTHER <br /> �.. OTHER - <br /> Deli vered - <br /> Receipt No. Permit No, <br /> Issuance Date Mailed <br /> Received by Dale 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERV10ES <br />