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•v ___ <br /> Applications Will Be Processed When Submitted Proper y> <br /> APPLICATION t _ vo <br /> F F.OFFICE USE: PUMP WELL <br /> (For Non-Transferable, Revocable,Suspendable) k <br /> ENVIRONMENTAL HEALTH PERMIT ; <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) <br /> Application isherebymadetotheSanJoaquinLocal HeaclthNost1ictf a dpermit <br /> he rules and regulations of instal <br /> theSarlwork <br /> oaquinherein <br /> ocaI Healdescribed, <br /> thTDistrictt.. y <br /> made in compliance with San Joaquin County Ordinan_300 ECity/Town � ik. Y1 <br /> Exact Site Address ✓, III. OT6 <br /> Phone <br /> Owner's Name fG r/ City <br /> AddressS License# Business Phone <br /> Contractor's Name . Emergency Phone i <br /> —Contractor's Address No i <br /> is Certificate of Workman's Compensation ance on File SRCpNDIT10N❑ DESTRUCTION❑ <br /> DEEPEN PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK). NE } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP 1NSTALLATIO <br /> REPLACEMENT❑ 11' 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 /> INTENDED USE TYPE OF WELL11 'TOOL Dia. of Well Excavation �I <br /> ❑ INDUSTRIAL ❑ DRILLED Dia'. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLICGRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ROTARY Type of Grout <br /> 13 CATHODIC PROTECTION 0 OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor' S H P <br /> PUMP INSTALLATION: A <br /> Type of Pump. v 111,1111,111 _ <br /> [3State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL <br /> Describe Material and Procedure <br /> work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and that_the f 4 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, A <br /> t's signature certifies the following:"I certify that in the performance of the work for <br /> Home owner or licensed agenwhichthis permit <br /> 1. an person in such manner as to become subject to workman's compensation laws of California." <br /> is issued, l shall not employ y P 1 certifythat in the performance of the work forwhichthis <br /> Contractor's hiring h ll employ persons <br /> e sonsng g ubiect to workman'nature certifies the s <br /> compensation laws of California." <br /> permit is issued, I shall employ p <br /> f I will C a G ut Inspec' n f r grouti and a final inspection. Date: <br /> l Title: <br /> It Signed X (Draw lot Plan on Reverse Side) <br /> FOR DEPARTME .T USE ONLY <br /> t <br /> k PHASE 1 ` <br /> Date <br /> Application Accepted By <br /> 'Additional Comments: Ph se III Final Inspection <br /> Phase 11 Grout InspectionInspection By ate <br /> Date <br /> Inspection By <br /> 31 <br /> REMIT <br /> � Fee Is Due: [3 ANNUALLY PER UNIT PER SITE ❑ EACH El January 1 &Receive$d By January 3tAM0❑TJDUEI &ReceiCHECKEDved By Y <br /> 64LLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANAT4ON DATE DATE <br /> I <br /> FEE <br /> LESS <br /> PRORATsON <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> s <br /> I <br /> E -OTHER _ <br /> 1 © �J/ issuance Date Malted Delivered <br /> Receipt No. Permit No. <br /> Received by Date '1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTDN,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO-. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />