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-_ _ -- � <br /> Applications Will Be Processed When Submitted Properly omp e e <br /> FOR OFFICE USE: APPLIC <br /> �' (For Non-Transferable, R bWSuspendable) <br /> PUMP&WELL <br /> 7� ENVIRONMENTAL. T$r4r� l 1980 <br /> ITRI <br /> �M. # WATER QUALITY ►r` <br /> (COMPLETE IN TRIPLICATE) <br /> Application ishereby�madetotheSanJoaquin Local HealthDistrictforapermittoc t,fl�ct3dJlnll -f��qurnlLocalHealth TDistrict, <br /> applicationls <br /> made in compliance ith San oaqui Co �, y Ordinance t� 862 and the rules�CY.La`�s�� � � A <br /> CY.L City/Town <br /> Exact Site Addr ss T ' <br /> ;G phone <br /> Owner's Name C City <br /> Address ` � <br /> f Contractor's Name !I "t License# �i7'd Business Phone <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certiticate of Workman's Compensation Lln❑suran EEPENon e❑With SRECONDITION❑ DESYRUGTION❑ <br /> TYPE OF WORK (CHECK): <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> t <br /> t yREPLACEMENTXI <br /> f y <br /> r Sewer Lines Pit Privy <br /> i DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Weil <br /> INTENDED USE <br /> TYPE OF WELL <br /> INDUSTRIAL i`, 19' CABLE TOOL Dia. of Well Excavation <br /> C] INDUSTRIAL <br /> « <br /> 9 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DRIVEN Gauge of Casing <br /> 13 DOMESTIC/PUBLIC <br /> I ❑ IRRIGATION il1 11 GRAVELPACK Depth of Grout Seal.- <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION 0 OTHER Other information (�- <br /> ❑ DISPOSAL II 4 Surface Seal Installed By: <br /> ❑ GEOPHYSICALIII <br /> PUMP INSTALLATION: Contractor <br /> N.P. <br /> Type of PumpC S <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: I <br /> 11 State Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> ' Describe Material and Procedure ------------------ <br /> l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, f <br /> ces, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance othe work for which this permit <br /> } is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> [ Contractor's hiring o r su b-contr <br /> acting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> 1 permi... issued, I shall employ persons subject to workman's compensation laws of California." <br /> f I will call for a Grou I speon rior to grouting and a final inspection. <br /> Title: <br /> F i cwt . Date: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> i OR EPART NT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: P ill Fin nspection <br /> Phase II Grout Inspection / � <br /> r inspection BDate <br /> inspection By Date <br /> � <br /> kkk !Ir ❑ January &Received By January 31 C] July 1 &Received By July 31 <br /> f Fee !S DUI: ❑ ANNUALLY " ❑ PER UNIT LPER S4YE .i- -❑ EACH JaY 1_ ., REMIT <br /> � EXPLANATION BILLING REMITTANCE AMOUNT OVE CHECKED <br /> - REMITTEp AMOUNT <br /> BASE - DATE DATE <br /> FEE - <br /> LESSIM Fp r <br /> PRORATION a�. �. <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A� <br /> Delivered <br /> 4 ' --• Receipt No: nnit No. Issuance pate Mailed <br /> Received by Date - A 95201 <br /> APPLICANT—RETURN ALL COPies TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1641 E.HAZELTON AVE.,AYEP.O.Box 2009 �STOCKTON, <br />