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Applications Will Be Processed When Submitted Properly Completed.Be SureTo Sign inem N,r�a,. <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable,"Revocable,Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> iRfATER QUALITY �/J fl( 4_O L <br /> (COMPLETE IN TRIPLICATE) rk herein the wo <br /> Application is hereby made to the San Joaquin LocalHe�Ceh�os1r862 a¢Phe rulesOnd re ulatdions oftth�e San Joaquin LoclC ea h Dis"tr*ctribed.This phcation is <br /> made in compliance with San Joaquin County <br /> Ordinance City/Town <br /> Exact Site AddressIv,7 <br /> § Phone <br /> pufrner's Name . <br /> Address r f: License# fLl-! Business.Phone <br /> Contractor's Name • tEmergency•Phone. e <br /> rir e– ' Q <br /> Contractor's Address No / ► <br /> is Certificate of Workman's Compensation Insurance on File <br /> ❑With SRECOPIDITION STRUCTION'❑ �- <br /> TYPE OF WORK-(CHECK): -NEW WELL. DEEPEN r R <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP,REPAIR V '\ <br /> REPLACEMENT❑ t <br /> Sewer Lines Pit Privy ' <br /> DISTANCE TO NEAREST: Septic Tank' _ . ,-� 1 Cesspool/Seepage Pit' Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Wel! <br /> ' TYPE OF WELL <br /> INTENDED USE Dia. of well Excavation <br /> ❑ lNDU57RIRL 11 CABLE TOOL � rj f• <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑DRIVEN a= <br /> GRAVEL PACK- -. Depth of Grout Seal � <br />' ❑ IRRIGATION _ Type of Grout <br /> ❑ CATHODIC PROTECTION ROTARY <br /> � <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: 1 <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 1 hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, slate laws, and rules and regulations of the San Joaquin Local Health Distract. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance m the work for which permit <br /> Is issued, I shall.not employ any person in such manner as to become subject to workman's compensation laws of California,"ali <br /> hiring or signature certifies the following:"I certify that in the performance of the work forwhich this <br /> Contractors <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wil calf for a Grout Ilpspe n prior to grouti g and a final inspection. <br /> Date: t <br /> ,l Title: <br /> Signed X <br /> (Draw to Plan on Rever •Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �� Date <br /> 14 <br /> By <br /> Additional Comments: Phase III Final Inspection <br /> phaso G Inspection yyDate ` <br /> Inspection By <br /> ate /� inspection By �4 <br /> ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received EBlviylTJuly 31 <br /> Fee is Due: C1 ANNUALLY ❑ PER UNIT ❑ PER SITE DATE PATE REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE <br /> 13REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> c <br /> OTHER <br /> OTHER <br /> 4 _ Mailed De4ivered <br /> Receipt No._ ,. Permit Noissuance Date <br /> - <br /> Received by _ Date - - - 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI715EAVICES _ <br />