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wx .t <br /> 'Applications Will Be Processed When SubAotiPtl�e Properly APPLICATION <br /> e <br /> AOR-AF'I'ICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY F <br /> (COMPLETE IN TRIPLICATE) ! <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit toconstruct and/arinstall thew herein described.This application Is <br /> made in compliance wl h San Joaquin County OrdinanceNo. 1862 and the rules and regulations of the San LVl9*i7 Local Health District. I <br /> I Exact Site Address 1u �rtR i�J D� 0� �� City/Town <br /> i�..y.l%.o Phone "' <br /> Owner's Nam — -� City CLA) I <br /> Address 1S fU C—%Nrc �� <br /> __ LZ, Business Phone <br /> Contractor's Name 1 / L31 #g ' <br /> er enc Phone <br /> Contractor's Address Yes No <br /> S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Y` _y <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ -!F Pit Priv ��+ <br /> DISTANCE TO NEAREST: Septic Tank <br /> 4 Sewer Lines .1`�C3 y <br /> Sewage Disposal Field t_� Cesspool/Seepage <br /> pit , Other <br /> Property Line 1�-- Private Domestic Well (��— Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ' <br /> INDUSTRIAL. 11 CABLE TOOL Dia. of Well Excavation l� c� <br /> + C3DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN 2p <br /> �O' t <br /> ❑ IRRIGATION 75 GRAVEL PACK Depth of Grout Seal <br /> s ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> El DISPOSAL <br /> ❑ OTHER Other Information ;Z <br /> 1:3 GEOPHYSICAL _ Surface Seal Installed By: <br /> i' PUMP INSTALLATION: contractor <br /> H.P. <br /> Type of Pump_ � .. <br /> PUMP REPLACEMENT:, '1❑ State Work bone <br /> f PUMP REPAIR: ❑ -State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> WelhDiameter <br /> . .t — .—=Describe-Material and-Procedure — <br /> 4� � 5kN <br /> I hereby certify that I have pr pared 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employtany person in such manner as to become subject to workman's compensation laws of California.' <br /> Contractor's hiring or_sub-contracting signature certifles the,following:"I certify that in the performance of the work for which this <br /> f California." <br /> pe it is issued, I shall employ persons subject to workman's compensation laws o <br /> I 11 it for a Gr t.Inspect' n rior to grouting and a final inspects ^ <br /> PDate: [� <br /> Title. <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I - <br /> PHASE 1Ko <br /> Date <br /> Application Accepted By t <br /> Additional Comments: J Phase IIIFinal fns ecti_ on <br /> haselll Grouw <br /> t Inspection _ f pate / g0 <br /> Date Inspection By <br /> Inspection By �.. <br /> rBy 31 <br /> ❑ ❑ ❑ PER SITE ❑ EACH C1 January i &Received 8y January 31 ❑ July 1 &Received REMIT Fee Is Due: ANN LY PER UNIT <br /> BILLING -REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE lb V <br /> C_ <br /> LESS <br /> PRORATION <br /> f4 . <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> VI5 an� ate Maiied Delivered <br /> Received by <br /> . D e Receipt No- Permit No. - <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ��� 1601 E.HAZELTON AVE,,AYE.,P.O:130K 2405 STOCKTON,CA 95201 <br />