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ly <br /> Applications Will Be Processed When Submitted PPLICArTIONp e e . t <br /> FOR OFFICE USE: For Non-Transferabie,Revocable;Suspendable) PUMP&WELL <br /> 174—K-41 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> {COMPLETE IN TRIPLICATE) a <br /> and the rules and regulations of the San Joaquin Local Health District. <br /> tion is hereby made to the San Joaquin LocalHAalthDistrict2forapermittoconsiructand/orinstalltheworkhereindescribed.T Is <br /> Application <br /> made in compliance with San Joaquin County Ordinance No. 18 City/Town , <br /> Exact Site Address 0 Phone <br /> i <br /> Owner's.Name 5 <br /> �c City <br /> 3- Lss Phone <br /> Address =:Busine <br /> - License -�2 <br /> "� Emergency:Phori <br /> Contractor's Name f +yr ��. � - _ .. <br /> Contractor's Address No <br /> ❑ DESTRUCTION❑ <br /> Is Certificate of Workman's Compensation insurance on File❑With 5RECONDITION' ❑ PUMP REPAIR <br />' NEW WELL❑.;. DEEPEN . <br /> TYPE OF WORK�i;CHECK):� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> REPLACEMENT L'/ Pit Privy <br /> Sewer Lines � "Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑-,, INDUSTRIAL 13A DRILLED Dia. of Well Casing <br /> 0+ -D ) f=STIC/PRIVATE 13 DRIVEN Gauge of Casing <br /> Lj`[�pME5T1C/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ .IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> (3 DISPOSAL Surface Seal Installed By: ,\ <br /> ❑ GEOPHYSICAL Contractor - 1 � �-� H.P. <br /> ✓� C <br /> PUMP INSTALLATION: r <br /> . Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> Approximate Depth <br /> PUMP REPAIR: <br /> Well Diameter <br /> DESTRUCTION OF WELL: <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 /> th District. <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local that inthe performance of the work for <br /> which this permit C <br /> Home owner or licensed agent's signature certifies the following: t to <br /> is issued, aws of California. <br /> I shall not employ any person in such manner as to fol owin e'I certify that in he performance of the lwork forwhi h this <br /> Contractor's hiring or sub-contracting signature certifies the 49 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California:" ] <br /> 1_will_ 11 fpr a Grout lnspe tion prior to grouting and a final Inspection. pate: <br /> Title: { <br /> Sig d X (Draw Plot Plan on Reerse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date - <br /> Application Accepted By <br /> Additional Comments: his Ill Final Inspection <br /> Phase 11 Grout Inspection Inspection By ��' Date <br /> Date '] <br /> inspection By <br /> R <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE �❑-EACH ❑ January 1 &Received EMIT ECKED <br /> d By January 31 AMOt�T DUE &Received <br /> 31 <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY - <br /> OTHER <br /> OTHER `` A - <br /> ^'1 r�'e, ed r <br /> - Issuance Date- Mai4pe4ivered <br /> Receipt No.. Permit No. <br /> Received by Date. + - icor E.HAZELTON AVE.,P.O.OM 2009 STOCKTON,CA 95201 r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES - <br />