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A{&i !tiWis IA P�Po ssAW ubmltted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> AUG 16 1982or Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT CCC//l <br /> t (COMPLETE IN TRIPLICATE)Ag��� AQUI�c� L��F( AL W7.ATER QUALITY:,. rr <br /> Application is hereby made toth�5"a6n�oa u1� 2S a1i a hDistrictforapermittoconstructand/orinstalIthework,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 66 Best Rd: ° ""` City/Town Sbckton <br /> ti <br /> Owner's Name +c Phone - ��°948-6604 <br /> F <br /> Address same F1M^ ' € `"' " City- <br /> Contractor's NameLicerrse#6769Business Phone 9141 14511 t) <br /> Contractor's Address " � " -� :'Emergency <br /> .Phorle, ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ' TYPE OF WORK (CHECK): 'NEW WELL 11 DEEPEN ❑ m RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 1311 V PUMP INSTALLATION �. PUMP REPAIR 1 <br /> REPLACEMENT IhlJt <br /> A <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> f Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE y " p" TYPE OF WELL r ` <br /> ❑ NDUSTRIAL CABLETOOL Dia. of Well Excavation <br /> Ikk DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC + ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION --( ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 13 OTHER Other Information <br /> ❑ GEOPHYSICAL ".„" ".�' <br /> - r �"` Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor s <br /> Type of Pumpsjl3bmarH.P. a <br /> f PUMP REPLACEMENT:- _ 30 State Work Done pUlled out puarp and replailzed with now one <br /> PUMP REPAIR: ❑ State Work Done. <br /> ' DESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure } -. <br /> I hereby certify that I have prepared this application and that the work will be done in'accordahce with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ' II <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thew ork forwhich this permit 3 1 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ,. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." s <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed <br /> r, <br /> Signed X _.. Title: z— �,. Date: <br /> (Draw Plot Plan on Reverse Side) f i <br /> r j FOR DEPARTMENT USE ONLY <br /> PHASE + <br /> Application Accepted AM I ©� Dated <br /> Additional Comments: <br /> Pha a II Grout Inspection <br /> ?_bairial Inspection <br /> IInspection By Date Inspection.By r11 4 Date <br /> 5 S ] <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE. ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received 8y July 31 t�I <br /> REMIT q <br /> I BASE" EXPLANATION BILLING REMITTANCE $ AMOUNT DUE = CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - r <br /> PLUS <br /> PENALTY. - - - <br /> OTHER �.. <br /> OTHER <br /> Received by Date Receipt No. - _ Permit No. soance Datd Mailed Delivered - I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />