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qc �toisWi�l Br`Pgices§ed Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I ' 1 APPLICATION <br /> (Fo Transferable Revocable;Suspendable) PUMP&WELL <br /> DEC 31 1982 ENVIRONMENTAL HEALTWPERMIT , " q�� I <br /> WATER.QUALITIf, �� ��`�0 s• n/o <br /> (COMPLETEPLICATEp.j �)A � � : n Ls tE � : �:. �.. f <br /> Application is hereby made to the SarlorIL �l District for a permit to cop struct and/or install the work herein described.Thiscapplication is <br /> made in compliance with San Joaquin Countyrdtina)nce No. 1862 a the.rules and regulations of the San Joaquin Local Health District., <br /> Exact Site Address ,S `� J City/Tpwn <br /> Owner's NameLXc..�_� ZXra� <br /> Address N e6o L�. :r;' cal i y u City. y, 1 <br /> iContractor's Name � '{ "h License 9&2, 3`7 Business Phone-- %Q 6^ r7' 6 -J Q <br /> Contractor's Address Emergency Phorie � � -1F � .� } -G' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I/ No <br /> t TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL,ABANDONMENT 11OTHER ❑ PUMP INSTALLATION 13PUMP REPAIRb—/ - <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines "Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 11 �vPublic Domestic Well <br /> t , <br /> I INTENDED USE �, STYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dial. of Well Casing <br /> C] DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing \V) <br /> IT IRRIGATION ❑ GRAVEL PACK Doth of Grout Seal f �~ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Othier Information <br /> ❑ GEOPHYSICAL- ace Seal Installed,e6'y:' r <br /> PUMP INSTALLATION: Contractor 0 � <br /> Type of Pump / H.P- 7 z <br /> PUMP REPLACEMENT: ❑ State Work:Done <br /> PUMP REPAIR: State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter j Approximate Depth <br /> Describe Material and Proced l a <br /> I hereby certify that I have prepared this application ancl4atlthe'wdrk will be done in accordance with San Joaquin Coubly j <br /> ordinances, state laws, and rules and regulations of the'Sar rJ quin l ocal Health District. <br /> Homeowner or licensed agent's signature certifies fhe folfovyriitg:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in suannr i to become <br /> ch subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature ceftifils the followings"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employpersons;6`6`bjed�e'workman's compe.�sstion laws of California." <br /> I w• call for-aGroutM,,�ectlon_prior It g and a final inspection: � <br /> Signed X N -'Date: <br /> E�A ( raw Plot Plan on Reverse ide) <br /> F� + FOR DEPARTMENT USEIONLY <br /> PHASE <br /> Application Accepted By / Date—2 <br /> } <br /> Additional Comments' t , ' ' <br /> Phase II Grout Inspection �r /P I Final Inspection �7 <br /> I Inspection 6y- _ Date Inspection•By, r'" �'� Date <br /> low <br /> Fee,IS DUE: IT ANNUALLY `� ❑'PER UNIT El PER SITE 1:1 EACH -January 1 &Receiv y Jan 31 ' ❑ Ju}y 1 &Received By July 31 <br /> GREMIT <br /> F i - - - BILLING- �..REMIITTANCE $•1 - <br /> BASE EXP-,LAN'A�TION !OL AMOUNT DUE CHECKED <br /> DATE RATS, RE I yy D AMOUNT <br /> c rti <br /> FEE <br /> LE55 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> {t OTHER <br /> —5 NVLAJ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed, . Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />