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ed <br /> ly <br /> w Applications Will Be Processed When SuAPtPL1CArTIONPreIw. <br /> PUMP&WELL <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) ui Local Health District. <br /> is hereby madeto theSan Joaquin Local Health Districtf a dp he rttles and regulatd'loons oftheSan Jk q rein described.This <br /> Applicationnce No.1862 <br /> made in compliance with San Joaquin County Or City/Town <br /> Exact Site Address phone <br /> i <br /> Owner's Name F 11 City 52 <br /> �7 <br /> Address /3 4 Z License#1��= Business Phone <br /> Contractor's Name Emergency Phone �'^ <br /> Contractor's Address <br /> � No <br /> Is Certificate of Workman's Compensation Insurance on File❑With S LHD?RECONDITION DESTRUCTION PUMP REPAIR nJ <br /> TYPE OF wORK (CHECK): NEW WELL❑ DEEPEN lJ <br /> WELL CHLORINAT N ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> REPLACEMENT Pit Privy <br /> Septic Tank Sewer Lines ether <br /> DISTANCE TO NEAREST: Sep Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> 13DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION M ❑ OTHER Other Information <br /> ❑ DISPOSRL � DSurface Seal Installed By: �. <br /> ❑ GEOPHYSICAL Contractorf' <br /> PUMP INSTALLATION' _ -.- H.P <br /> Type of Pump Q __X_— tl <br /> C�State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ; Approximate Dept <br /> PUMP REPAIR: h <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Ovules and regulations of the San Joaquin Local Health District" <br /> g.., y 1 <br /> manner as to become subject to workman's compensation laws of California." <br /> Home owner ar licensed agent's signature certifies the following- l certify that in the performance of the work for which this perms <br /> is issued, I shall not employ any person in such <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this <br /> ject to workman's compensation laws of California." <br /> permit is issued, l shall employ persons sub <br /> I wit c II fo Grout In ction prior to gr uting and a��fiJJnal inspection Date: 1/ <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> / _ <br /> PHASE I ._0 <br /> Date`'��`" <br /> Application Accepted By I <br /> Additional Comments: a IN�Fi ction F� Q <br /> phase It Grout Inspection inspection Sy / I7 <br /> Date <br /> inspection By 1 &Received By July 31 <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July REMIT <br /> Fee is Due; ❑ ANNUALLY ❑ PER UNIT $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r� <br /> J` I ante Date Mailed Delivered <br /> Receipt No. Permit No. STOCKTON,CA 95201 <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Bo:2609 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERy10E5 <br />