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AppAPPLICATION= .. �. <br /> lications WIII Be Processed When Submitted Properly omp e <br /> . FOR OFFICE USE: �� AU G 23 1979 <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> k ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> WATER QUALITY HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) <br /> is <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application <br /> made in compliance with San Joaquin County Or ante No-�2 and the ruI s and regulations of the San Joaquin uin Loc 1 Health District. <br /> © City/Town <br /> Exact Site Address ' ? <br /> Phone <br /> Owner's Name City <br /> Address 1 License Busipess Phone <br /> 's Name <br /> Contractor • `J <br /> ����� Emergency Phone <br /> Contractor's Address No tet <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Ye -� �STRUCTION❑ •`! <br /> TYPE OF WORK (CHECK). NEW WELL C1 DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION C3WELL AB Q�0 Mx/E T&M P c9u4 b rINSTALLATION sel2V�-0651 �yM C7w� <br /> W <br /> REPLACEMENT❑ Pit Privy 1 <br /> Sewer tines � <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well -j <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> C1 DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PRIVATE Gauge of Casing <br /> 13DOMESTIC/PUBLIC 13 DRIVEN <br /> '• ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ` 11CATHODIC PROTECTION ❑ ROTARY Type of Grout fa`1 <br /> ❑ DISPOSAL ❑ OTHER Other Information N <br /> ❑ GEOPHYSICAL Slf� face Seal Installed By: <br /> PUMP INSTALLATION: Contractor � / <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done "~ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> C Home owner or licensed agent's signature certifies the following:"I certify that in the performance of theworkforwhichthis permit <br /> i 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 /> f permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> I will c r a out Inspect prior grouting and a final in C111072 <br /> Title: Date: <br /> ` Signed X {Draw Plot Plan on Reverse Side) <br /> FO DEPAR MENT USE ONLY <br /> l PHASE I �yy� Date 2 7 <br /> Application Accepted By <br /> Additional Comments: Ph e 1 Final I pection�+ c/ <br /> Phase 11 Grout Inspection A Date !` T — <br /> f inspection By <br /> Date Inspection By <br /> ' <br /> January 31 0 Ju <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH . ❑ January 1 &Received By July 1 &ReceivREMITBy Iy 3I <br /> ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE- "=.�. DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> - PRORATION - <br /> 1 PLUS <br /> PENALTY <br /> { OTHER <br /> i <br /> r- <br /> OTHER <br /> Receipt Nv. - Permit No. - Issuance Date Mai4ed Delivered <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES-` ... 1601 E.HAZELTON AVE.;P.O.Box 2609 5TOCKTON, <br /> Received by Date CA 9 � <br />