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- Fi <br /> Applications Will Be Processed When Submitted Properly Compieteo. <br /> APPLICATION � <br /> FOR OFFICE USE: (For Non-Transferabl6, Revocable,Suspendable) pump &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSanJoaquin LocalHealth <br /> Nos1862 a dtrict for a pthe rules and regulations ofthe San Joaquin Local Healltth District.This .application Is <br /># made in compliance with San <br /> Joaquin Copunty Ord1l� aBlSnv City/Town SfpcaE 7 l <br /> V �! IfI /�! �C <br /> IfC Psi E / 3 p� <br /> t Exact Site Address /� / 2 2 / <br /> . CSI,�X `,`, <br /> Phone <br /> Owner's Name City "S <br /> Address !� !CS Business Phone� �� 37�" 8-239 <br /> Ter (r'��•Fr icense# <br /> Contractor's Name Se-�fc . Emergency Phone � <br /> Contractor's AddressNo <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑1DESTRUCTIONX <br /> TYPE OF WORK (CHECK): NEW WELL,„ DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION 11WELL 'ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR 13 <br /> t REPLACEMENT❑ Sewer Lines Pit Privy <br /> v DISTANCE TO NEAREST! Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field 'Public Domestic Well <br /> Property Line Private Domestic Well <br /> � <br /> TYPE OF WELL 401 <br /> INTENDEDUSE Dia. of Well Excavation <br /> 11 INDUSTRIAL <br /> 11 CABLE TOOL <br /> I Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATEDRILLED <br /> DRIVEN Gauge of Casing <br /> 13DOMESTIC/PUBLIG ❑ GRAVEL PACK Depth of Grout Sea; <br /> I ❑ IRRIGATION <br /> ROTARY Type at Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> F-1DISPOSAL C3 OTHER <br /> Surface Seal Installed By: <br /> A GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ,y Approximate Depth SO <br /> DESTRUCTION OF WELL: Well Diameter �� I <br /> Describe Material and Procedure <br /> 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 at the San Joaquin Local Health District. <br /> Hr or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Home owneissued, I shall not employ any person In such manner as to become subject to workman's compensation laws of California." <br /> is ture certifies the following:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring t subcontracting signa <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> VV25�����an <br /> nd a final inspection. �� <br /> Title: S . -.^'i�"""I'� �- Date: <br /> Signed X <br /> on Reverse Side) /�� ///,o 3 <br /> f FOR DEPARTMENT USE ONLY <br /> PHASEI ��^' <br /> �1�4+C..► Date <br /> Application Accepted By <br /> Additional Comments'. Phase Ill Final Inspection <br /> Phase II Grout Inspection Date <br /> l Inspection By___l�[t;rR <br /> Date Inspection By <br /> PER UNIT ❑ C1 EACH ❑ January 1 &Received By January 31 ❑ July t Received By July 31 <br /> Fee IS Due: El ANNUALLY PER SITE❑ REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> f BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE RQ„ <br /> LESS ` <br /> PRORATION <br /> t PLUS /0 <br /> 'PENALTY y. <br /> OTHER ^^' <br /> OTHER <br /> ed Delivered <br /> Date Receipt No. Permit No. <br /> Issuance Date Mail <br /> Received by 1601 E.HAZELTON AVE..P.O.Box_2009 5TOCKTON,CA 95201 <br /> ` APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL REALTH PERMIT/SERVICES <br />