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Completed. BeSureToSign 1no <br /> Applications Will Be Processed When Submitted Properly <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> ork lication is', <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin LOrdinacal ncehNo5t1862 andrict for 8 the It les and regulatd-+-+ons oftthe Sart Jo quint Local Health TDistrriictt.. <br /> made in compliance with San Joaquin County City/Town <br /> j s. G <br /> Exact Site Address _L�I�s � 5 �> -7-2— 1'# <br /> 1 Owner's Name F:r� <br /> Phone <br /> t Address <br /> }+ ; r License#" C?c.J��� Business Phone= <br /> Contractor's Name `. t -. _ rr, `xtEmergency Phone" ` <br /> j Contractor's Address No - <br /> i es <br /> Is Certificate of Workman's Compensation Insurance on File With 'R CONDITION❑ DESTRUCTION❑' <br /> TYPE OF WORK"(CHECK): NEW WELL DEEPEN <br /> � NDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABA <br /> REPLACEMENT❑'' , . . -- <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other «I <br /> Sewage Disposal Field Public Domestic Well prti <br /> Property Line Private Domestic Well <br /> TY OF WELL i <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL s^- ❑CABLE TOOL <br /> DTlk'RILLED Dia. of Weli Casing i <br /> kDOMESTICIPRIVRTE t ❑ DRIVEN Gauge at Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK: Depth of Grout Seal ` <br /> ❑ IRRIGATION u <br /> Type of Grot <br /> El CATHODIC PROTECTION ❑ ROTARY kE <br /> ❑ OTHER Other Information t <br /> ❑ DISPOSAL Surface Seal Installed By::, <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor li P <br /> Type of Pump F <br /> 4 <br /> PUMP REPLACEMENT:F ❑ State Work Done <br /> "�s> S t <br /> PUMP REPAIR: <br /> ❑ State Work Done App roxiinate Depth <br /> DESTRUCTION OF WELL: Well-Diameter j <br /> Describe Material and Procedure I <br /> I hereby certify that 1 have prepared this ap onsplicatioh and that the work <br /> laccordance with San Joaquin County <br /> of the San Joaquin n LocalHealtth District <br /> ordinances., state laws, and rules and regu <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of theworkforwhich this permit <br /> }is issued, i shall not employ any person in Such manner as to become subject to workman's compensation laws of California." - <br /> Contractoishiring or sub-co signature certifies the following: 'I certify that in the performance of the work for.which this <br /> permit is issued, l shall employ persons subject 10.w <br /> permit <br /> compensate laws of California." <br /> n r too grouting and a final'inspection. <br /> I will li for a Grou P �� pate: <br /> k _ <br /> Title: y , <br /> Signed X I (Draw Plot Plan on Reverse Sid ) " <br /> ,# <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 r Date _ =�- <br /> Application Accepted By <br /> Additional Comments: e r P as �111FInal Inspection <br /> Phase 11 Grout Inspection Date ��"� <br /> ate inspection By <br /> Inspection B <br /> _ �. <br /> PER UNIT ❑" " ❑`EACH ice❑ January 1 &Received By January'31-; ❑ July:1'&'Received By Jvly 3t <br /> PER SITE <br /> Fee IS Due: ❑ ANNUALLY ❑ it <br /> REMIT <br /> CHECKED <br /> BILLING" REMITTANCE $'` - AMOUNT DUE AMOUNT <br /> BASE EXPLANATION DATE t DATE REMITTED j. <br /> FEE W - <br /> a <br /> .LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -k - <br /> OTHER <br /> Permit-No Issuancet7ate 1 -Mailed _Delivered <br /> ec <br /> Received by D te" <br /> Receipt No. t <br /> " � "�' 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 —� <br /> APPLICANT—RETURN ALL COPIES TO: 1ENVIR014MENTAL HEALTK PERMIT/SERVICES <br />