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—� p - <br /> Applications Will Be Processed When SuAPPL{CATIONp`eieu. oo�,.ra a•. - <br /> '� FOR OFFICE Ud Properly <br /> SE: <br /> (Fol Non-Transferable,Revocable,Suspendable) pUMP&WELL <br /> I <br /> t — ENVIRONMENTAL HEALTH PERMIT <br /> t - ,s VATER QUALITY ?n�� ((o--(0 <br /> (COMPLETE IN TRIPLICATE) q o t s f'F <br /> Application is herebymadetotheSanJoaquihLocalHealthDistrictforapermittoconstructand/orinstallthework herein described.This application is`, <br /> ` made In compliance with San Joa in County Ordinance No. 18�i2 ani toe rules a d regulations of the San Joaquin Local Health District. <br /> �a� 1l__L/ City/-Towp _ <br /> r � aA <br /> Exact Site Address y2_ <br /> �oe46- -/,,AAs a hL-" <br /> Owner's Name ltJ lCity <br /> Address ���- Business Phone I <br /> � License <br /> C Contractor's Name Emergency Phone _ -— <br /> I <br /> i Contractors AddreP_ O No <br /> is Certificate of Workman's Compensation Insurance on File ith SJLHD7 Yes <br /> NDITION 13 DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECO <br /> I WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER <br /> ❑ PUMf INSTALLAT PUMP REPAIR❑ <br /> O <br /> REPLACEMENT❑ -t <br /> DISTANCE TO NEAREST: Septic Tank <br /> Se(;..roes, I Pit Privy; <br /> I Sewage Disposal--Fietd _Cesspool/Seepage Pit ' �_— Other <br /> i Private Domestic Well _ Public Dom>3stic-Well <br /> Property Line_ <br /> TYPE OF WELL <br /> INTENDED USE T µ' Dia. of Well Excavation�' �- <br /> ❑ CABLE TOOL <br /> ❑ INDUSTRIAL , <br /> �OMESTIC/PRIVATE El DRILLED Dia. a Well Casing <br /> C1DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ ROTARY Type of Grout <br /> C3CATHODIC PROTECTION ` t - (._�.-, y <br /> ..-- a- OTHER then-Inlormatlon_�— <br /> I, ❑ bJSROSAL - <br /> . z,� -.% C }{ j Surface Seal Installed By: <br /> ❑ GEOPHYSICAL — <br /> : Contractor <br /> PUMP INSTALLATION— - - / <br /> Type <br /> of Pump— f <br /> PUMP REPLACEMENT.. 11 State Work Done_ <br /> PUMP REPAIR: <br /> 11 State Work Done <br /> Well Diameter Approximate Depth <br /> i DESTRUCTION OF WELL: — <br /> I Describe Material and Procedure_ { <br /> r at I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ( 1 hereby certify that P <br /> ordinancesttate laws, and rules and regula <br /> itions of the San Joaquin Local Health District. <br /> rHome ownerorlicensedagent'ssignaturecertifiesthefollowing:'•IcertifythatintheperformanceoftheworkforwhichthisPermit <br /> r is issLed, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i g:' <br /> Conttr Zrors hiring or sub-contracting signature certifies the <br /> following: I certify that in the performance of the work for which this <br /> }permit is Iss}ed, I shall employ persons subject to workman's compensation laws of California." <br /> 'I 1 Grout Ins action prior to grouting and a final inspection- <br /> Title: <br /> Date: <br /> 5;g , v (Draw Plot Plan on Reverse Side) <br /> 1 FORD PARTM T USE ONLY q <br /> PHASE I Date �/ <br /> f Application Accepted By <br /> Additional Comments: -,ph a III Final Inspection <br /> Phase 11 Grout Inspection <br /> Inspection By <br /> Date _ Inspection By <br /> PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July eceived By.''uly 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> l �y <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER — <br /> OTHER <br /> f :___113� � <br /> Permit No. issuance Date Mailed Delivered <br /> DaM Receipt No. ~ <br /> Received by 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCI(TON A 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �, <br />