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' .'AppNcations wWill a Processed When Submitted Properly Compleieo. oe OUFU -•2,•• �r <br /> APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT j cei_ <br /> - 'WATER QUALITY y� <br /> � .� <br /> (COMPLETE ltd TRiPLICATE)fiaRa*r0ocal <br /> w `` <br /> Application is hereby madetc Hea�IthiDostric f andPhe ides and regulations ofithe San ora Joaquin)LocalcHealltthTDistrictis his i atior Is <br /> made in compliance with Sh S nCo rdlnzn,"eCity/Town <br /> Exact Site Address Phone 34012� <br /> Owner's Name City , <br /> Address C ense Business Phone <br /> Contractor's Name k o <br /> f , '/ r r� # <br /> ���� � 07 Emergency Phone 3 <br /> Contractor's Address, No �- <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I, _n �+ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPENN ❑ OTHER <br /> E ❑ PU�p DESTRUCTIONO <br /> INSTALLAT ON�` PUMP REPAIR❑ L{Inv <br /> WELL CHLORINATION ❑ WELL ABANDONMENT a, <br /> REPLACEMENT❑ Pit Privy A- 0 <br /> Sewer Lines ,,,/ I <br /> i DISTANCE TO NEAREST: Septic Tank _ _ Cesspool/Seepage Pit .fug%✓ Other <br /> .Sewage Disposal Field /)af,e Public Domestic WellIA2d`� j <br /> i r t Property Line, 'Private Domestic Well <br /> TYPE OF WELL /.2 /10I <br /> INTENDED USE �,/ Dia. of Well Excavation <br /> ❑ DUST1ilAL. .,' 94ABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ (aONIESTICIPIJBLIC - 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATIO.N-y <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODI'C PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL «. <br /> surface Sea4 lnsta�d By <br /> ❑ GN <br /> s : t <br /> PUMP INSTALLATION: Contractor - <br /> GEOPHYSICAL ` ; I.C.40 <br /> ' �/ � <br /> Type of Pump <br /> C3State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: - <br /> Well Diameter <br /> - Describe Material and Procedure <br /> application and that the work will be done in accordance with San Joaquin County I hereby certify that I have prepared this <br /> P <br /> r, ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ties the V Home owner or licensed agentt'Is signaturen such mannerastogbecomtefsubject to workmanythat in the as compensationnce of the work f�aws of California." <br /> is issued, I shall not employ y P g:„ y <br /> in the <br /> x v <br /> �. <br /> Contractor's hiring or sub-colo ra arsons subject tatifies the workman's oll ompensationcertify <br /> l wstof Calipornpamance ofthe work for which this <br /> permit is issued, i shall employ p <br /> I w' all for a Grout Inspe on rior t grouting and a final inspection• Date: <br /> 1, Title: _ <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE i Date <br /> I Application Accepted.By <br /> Additional Comments: P s III Fina nspect" - <br /> ° s IG rout _ spection�, y Date�� c� <br /> G - .yr^---ter <br /> Date �/ Inspection By <br /> lnspectiorn-B t i <br /> .. . <br /> - PEA U IT',= �❑ PER SITE ` ❑ EACH ❑ January 1 R Received By January 31 C3July 1 &ReceiveRd MyITuly 35 <br /> �-Fee-Is Due:"❑"ANNUALLY � REMITTANCE $ AMOUNT DUE CHECKED <br /> -BILLING REMITTED AMOUNT <br /> G <br /> BASE EXPLANATION DATE DATE ( <br /> � FEE <br /> E <br /> LESS <br /> PRORATYON <br /> PLUS <br /> PENALTY <br /> L OTHER <br /> OTHER <br /> l Issu nce ate Mailed Delivered <br /> c - - Receipt No. Permit No. 2004 STOCI(TON,CQ 95205 <br /> _Received by •D to - ,_.5605 E.HAZELTON AVE,,P.O.Box _ <br /> 4 -APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES ,� _ <br />