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pWhen Submitted Properly APPLICATION wu•v -- -� - - <br /> p rions Inas <br /> " U a <br /> rFOR OFFICE <br /> USE: P it `�;�tp1�' n_Transtereble, Revocable,Suspendahle) PUMP&WELL <br /> O S1 ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) osquin Local an <br /> madAppleemticompfan <br /> fiancewithth Sao Joaquin Countyrdinance No. <br /> 1f 11762 and the rales and construct <br /> oftthle Sen Joaquithework n Lo4a1 Healtnn described.TDishist plication Is <br /> `t , _� L,abT6Vul� w t. <br /> City/Town /.551 <br /> M <br /> I Exact Site Address W`G �Pp S� <br /> / Q Phone <br /> Owners Name E�V2G /LBS City ,6si�� <br /> j Address •License tic35' L Business Phone <br /> II#,� Contractor's Name - Emergency Ph ne ?- <br /> Contractors <br /> Contractor's Address oA, No <br /> I. Is Certificate of Workman's Compensation Insurance on File With SJLH04 yes�fd-- <br /> I NEW WELL DEEPEN 1:1RECONDITIONO DESTR <br /> TYPE OF WORK(CHECK): UCTIONS <br /> I WELL ABANDONMENT OTHER [] , PUMP INSTALLATION Ie PUMP REPAIR- <br /> WELL CHLORINATION 13 <br /> REPLACEMENT - Sewer Lines Plt PrrvY �— r <br /> ( DISTANCE TO NEAREST: Septic•Tank Cesspool/Seepage Pit <br /> y Line Public Domestic Well <br /> Other �.. <br /> Sewage Disposal Field <br /> j Propert Private Domestic Well O <br /> TYPE OF WELL <br /> INTENDED USE IJ CABLE TOOL Dia.of Well Excavation <br /> INDUSTRIAL ❑ DRILLED Dia.of Well Casing <br /> j ❑ DOMESTIC/PRIVATE 0 DRIVEN Gauge of Casing <br /> L ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION 11 OTHER Other Information . 1 <br /> ❑ DISPOSAL /' f Seal installed By: O <br /> I GEOPHYSICAL �( C <br /> E3 <br /> tractor H.P.Con — <br /> PUMP INSTALLATION: Type of Pum -" <br /> p... <br /> PUMP <br /> 1. ❑ State Work Done �° l <br /> ' REPLACEMENT: SLState-WGrk Done-� R� �OANA r lY/Co., l <br /> ' PUMP REPAIR:- ' Approximate Depth <br /> 1 DESTRUCTION OF WELL: Well Diameter— <br /> Describe <br /> iameter Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordanceInSan Joaquin County <br /> ordinances,state taws,and rules and regulations of the Sen Joaquin Local Health District. <br /> t Home owner or licensed agent's signature certilles the lollowing:"I certify that in to workman'sperformance <br /> omper)vJork forw of California."H issued, I shall not employ any person in such manner as to become subject to workmen's compegsetion'laws of aliforia." <br /> Contractor's hiring or signaturece <br /> tortwoekman'sil compensatioowing:"I n lawstof Caliin the fornia." pf the work forwhich this <br /> ,. permit IS is ued. I shall Y-901 <br /> I 1 al a Gro t Pe on r to grouting and a final inspection. 7 <br /> bate: <br /> Title:. <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> h <br /> t` FOR DEPARTMENT USE ONLY D� <br /> PHASE 1 y ,Date(!-_L—O <br /> k .Application Accepted By L <br /> Additional Comments: . h e 1 1 Final Inspection <br /> Phase 11 Grout InsPaclion Inspection By Date <br /> ' Inspection By <br /> Date <br /> REMIT <br /> Fee Is DUs: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE f3 EACH U January 16 Received By JanuerY 31 ❑ JuIY 1 &Received BY JuIY 31 <br /> .t - BILLING REMITTANCE AMOUNT DUE AMOUNTD <br /> BASE SkPLANATION DATE DATE REMITTED <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY (y ' <br /> 7� <br /> f OTHER <br /> OTHER <br /> 7 <br /> Date Receipt No. <br /> Permit Na. Iswence Date Mailed pellvBred' <br /> Received by. 1601 E.HAZlITOH AVE.P.O.Boa 2W1 STOCxTON.CA 95101-- <br /> APPLICANT-RETURN., COMES TO: ENVIRONMENTAL HEALTH PERMR/SERVICES <br />