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Apply I is flliilfC�e Diode^^'q dH n2rierable, <br /> hied Properly Completed- Be Sure To Sign The Application. .�V, <br /> �� li LDELIGATION <br /> I FOR OFFICE USE: - <br /> dona�� pI ( r Non- Revocable, Suspendable) PUMP & WELL <br /> RU 0 2 C IRONMENTAL WEALTH PERMIT ] <br /> 1 SAN t " � " 1 WATER QUALITY.(COMPLETE IN %TRIPLICATE , L, . N LOCAL ,.. � ! '-^ �f f - 'I-� " <br /> Application is hereby madeto theS" �aagcjinl .(-o����lE�:(tF�F1[strict.fora rm tocohslructand/or installthe work ei described . Th's application is <br /> made in compliance w' S Jo Coun r finance N 862 a _ r 1 S d regulations of the San ca , 4 <br /> +t City/Town . . <br /> Exact Site Address <br /> Owner's Narn 'e` J - Phone"r <br /> Address r . _ 4. city s - `J <br /> Contractor's Name --J ense # Busl s Phone ' - <br /> Contractor's Address Emergency Phone - - <br /> Is Certic <br /> lt _ate of Workman's Compensation Insurance an File With SJLHD4 Yes �� _ No <br /> TYPE OFWORK (CHECK): NEW WELL <br /> DEEPEN❑ RECONDITION FS DESTRUCTION ❑ • <br /> WELL CHLORINATIO -❑ •- WELL; ABANDONMENT ❑ OTHER 11PUMP INSTALLATION PUMP REPAIR❑ - 6 <br /> REPLACEMENT ', - - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private bomestic Well Public Domestic, Well - ; ( <br /> • ' INTENDED USE' + l l --- TYPE OF WELL -'-"•.� '."�` <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 - 0 ROTARY Type'bf Grout - <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> ❑ GEOPHYSICAL • Surface Seal Installed By: <br /> PUMP INSTALLATION: I . contractor _ <br /> I 'Type of Pump H. P. - - <br /> PUMP REPLACEMENT: : - O'State Work Don <br /> PUMP REPAIR: I ❑ State Work Dan <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure k <br /> I hereby certify that 1 have pYepared 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 owneror 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 ri toy tiny person In such manner as to become subject to workman's compensation laws of California." .. <br /> Contract ' rl g rsub-contra Ignature certifies the following:: c I that in the performance of the work forwhich this <br /> permi s—,*uesh ll a pl 6ypersons subject to workman's compen t' n laws of California.'I will cpeeti`o - p -or rout' lid a final inspecll -SfgnBd XI - T1tle: _. :Date(Draw Plot Plan O averse Side) <br /> I <br /> f ' FOR DEPARTMENT USE ONLY - <br /> • PHASE 1 - . . - L � .• ' AY�n /AAti� . _ 4 f"2cL. I Date —97, �I <br /> 'Application Accepted $y =. <br /> AdditionalComments:; <br /> r Phase II Grout inspection - ase III tion <br /> : Inspection-By . ' ILII : Date - - - Inspection B ate <br /> ' Fee Is Due: ❑ ANNUALLY ❑ ?ER UNIT ' O PER SITE ❑ EACH - 0 Janua & Received a nuary 31 July 1 8 Received 9y July 31 <br /> REMIT <br /> BASE - � EXPLANATION BILLING L - " REMITTANCE S ' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED, AMOUNT <br /> FEEy - <br /> LESS <br /> PRORATION <br /> l PLUS i - " I <br /> PENALTY <br /> OTHER 1I <br /> OTHER _ <br /> Received by ' _ ^ Date -' -heceipt No. . w Li- -' - Permit No. . - w Issuance a e - - Mailed . OellvereU- -- <br /> APPLICANT—RETURN ALL COPIES TO'I ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E, HAZELTON AYE., P.O. Box 2009 STOCKTON, CA 95201�� <br />