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__::: --- �— LJ <br /> Applications Will Be Processed When Submitted Properly Complete e�� <br /> APPLICATION <br /> FOR OFFICE USE: For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH.PERMIa1,N -nr4L <br /> WATER QUALITY ibeu i <br /> (COMPLETE IN TRIPLICATE) <br /> n descr <br /> Application is hereby made to the San JoaquinLacalHehNost1862andrict for a Phe rutlesand egulattiionsoftthe S nJoaquinlLocalHealthDistrriic.t,This , tioni+ <br /> made in compliance with San Joaquin County Ordinancei o. City/Town w� <br />' Exact Site Address <br /> � � ,h�' Phone i <br /> Owner's Name +`] City_ ' <br /> Addressff� � , 3 Business Phone "7 4/S cl <br /> Contractor's Name <� '"' 'r- ` `_ License#ii a ` <br /> n, 1- L Emergency Phone <br /> Contractor's AddrA No <br /> i Is Certificate of Workman's Compensation Insurance on File With SRECO Yes ❑ DESTRUCTION <br /> i TYPE OF WORK (CHECK): NEW WELL��'�DEEPEN ❑ RECONDITION <br /> l WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Bim{ PUMP REPAIR <br /> REPLACEMENT❑ % Q Pit Privy <br /> (� � Sewer Lines - <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit . Other <br /> Sewage Disposal Field _ Public Domestic Well <br /> Property-Line- <br /> INTENDED <br /> roperty Line �'� � Private Domestic Well <br /> ' INTENDED USE Y TYPE OF WELL I <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIAL Dia. of Well Casing <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED <br /> 11 DRIVEN R Gauge of Casing G <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ► Type of Grout a G C <br /> ❑ CATHODIC PROTECTION ©`iiOTARY <br /> ❑ OTHER Other information <br /> ❑ DISPOSAL I '� SuaceI inaBrrf <br /> 13 GEOPHYSICAL <br /> CQr�t��Ctor r <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump1 <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> PUMP REPAIR: ❑ State Work Done E ` Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter . <br /> 1 <br /> 'Describe Material and Procedure <br /> I hereby certify that I have preparaedd reisulationstof the San JoahquinoLocalllHealtbe dh District one in accordance with San Joaquin County j <br /> r <br /> ordinances, state laws, and rules 9 l �v <br /> Home owner or licensed agent's signature certifies the following."I certify that in the performance m the work for which ali permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grqutl spection prior tomrouting and a final inspection. ' <br /> Date: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I �' Date •- '" "- <br /> f9l <br /> Application Accepted By <br /> Additional Comments: <br /> ha e l I inal Inspection <br /> Ph e 1 rout inspection y 1�p �. Inspection By Date <br /> Inspection By Date <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I❑ PER SITE"� ❑ January 1 &Received By January 31 [3 July 1 &Received By July . <br /> EACH <br /> REMITTANCE $ AMDUNT DUE CHECKED <br /> BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> D <br /> FEE <br /> 7w LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> — J Issuance Date Mailed Delivered <br /> ata Receipt No. Permit No. <br /> Received by 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br /> APPLICANT—RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />