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Applications Will Be Processed When Submitted ProperlyCompteiea -4W <br /> APPLICATION <br /> FOR OFFICE USE: PUMP&WELL <br /> (For,Non-�ransferabie, Revocable,Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITYrk application is <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San JoaquinLocalnencehNo51i362andphe,rulesand regulatdioorinstthal le San Joa einlLoethe wo <br /> at Health District.scribed.This <br /> 4iance vylth San Joaquin Count Ordl n Q Q <br /> made in comp ) 1 �J f t! j'� __City/fown <br /> Exact Site Address / Phone <br /> ir <br /> Owner's N e City <br /> Address r License# QC <br /> 3 Bus'mess Phone <br /> a <br /> Contractor's Name Emergency Phone <br /> Contractor's AddressYes �/� No <br /> Is Certificate of Workman's Corrtpensatiori-Insurance on'File❑With SRECOND17lON❑ DESTRUCTION❑ l] <br /> TYPE OF WORK(CHECK): NEW WELLEEPEN D <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP IhlSTALLATION,� PUMP REPAIR❑ <br /> REPLACEMENT❑ t Pit Privy <br /> D Sewer Lines Other <br /> DISTANCE TO NEAREST: Septic Tank ? Cesspool/Seepage Pit <br /> Sewage Disposal Fields - Public Domestic Well . <br /> Property Line Private Domestic Well <br /> rop <br /> :. ,. y �OF WELL 'r N <br /> INTENDED USE Dia. of Well Excavation ` <br /> GABLE TOOL <br /> ❑'INDUSTRIAL Dia. of Well Casing - s <br /> ❑ DRILLED a� <br /> DOMESTIC/PRIVATE [I DRIVEN Gauge of Casing <br /> I�. IC/PUBLIC f Grout Seal <br /> L] DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth • <br /> ❑ IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ ROTARYIr <br /> ❑ OTHER Other Information ,1 y, <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> Ua <br /> ❑ GEOPHYSICAL �t ]j h <br /> Contractor H p, <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done _ , <br /> PUMP REPLACEMENT:_ ..-� ,. <br /> PUMP REPAIR: Y <br /> ❑ State Work Dorie <br /> c _ _.;—Approximate Depth <br /> M DESTRUCTION OF WELL: <br /> - -I-. 'Well Dlameter �`""�` <br /> Describe Material and Procedure `� <br /> I hereby certify that I have prepared this application and tihat the work will be done in accordan'311ce with San Joaquin County <br /> ealth District, 41 <br /> ordinances, state laws, and rules andregulations cert f esof the SaIi the following:Joaquincert fy thlatfin the perfoTmo f fie Worklforwhich this permit <br /> g: , <br /> Home owner or licensed agent's signal <br /> an-s�compen5ation laws of California.' <br /> t is issued, I shall not employ any person in such manner as to become subject to�w,ork <br /> i Contractor's hiring or sub-contracting signature certifies lhe:followm.g:;�t ertify`that in the performance of the work for which this <br /> permit is issued, 1 shall empmpensatio <br /> n laws of Cal LN <br /> loy persons subject to workman's conisi <br /> II I will call for a Grout Inspection prior�lo grouting and a tin inspection. ,) pate: <br /> I` Title: <br /> Signed X } I <br /> (Draw Plot Plan on Reverse Side) r_ <br /> � t M <br /> I <br /> f FOR DEPARTMENT USE ONLY j <br /> 00L— Date7� <br /> FAISc <br /> on Accepted By } r <br /> �n m <br /> al Comments: .k 1 p ha III Fi I inspection <br /> h II Gr t Inspection Date <br /> 4 Inspection By <br /> ection By Date S-, <br /> ❑ PER SITE IJ EACH I ❑ January 1 &Received By Sanuary 31 ❑ Juiy 1 &Received By July 31 <br /> ❑ PER UNIT ., REMIT <br /> ile: ❑ ANNUALLY F REMITTANCE $ AMOONT DUE CHECKED <br /> - BILLING REMITTED £ S 4 AMOUNT <br /> BASE EXPLANATION DATE e DATE ' - <br /> s <br /> FEE <br /> LESS <br /> ti PRORATION <br /> k PLUS <br /> PENALTY <br /> 4. <br /> - OTHER .,r. .. <br /> .OTHER - 27 ..� ... <br /> STOCKTO <br /> Receipt No. P <br /> ISS uan a Date Mailed De"vered <br /> .Received by 'Date ermit No. E <br /> 1601 E.HAZEL70N'AVE„P.O.Box 2064 N,�5261 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT—RETURN ALL COPIES 70: - _ <br />