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chlf'oli?Will Bay P" ceiLed Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE_USE: ; ' �-= APPLICATIQN <br /> (Fo -Transferable, Revocable,Suspendabfe) PUMP&WELL <br /> --- DEC 1 9,82 <br /> ENVIRONMENTAL HEALTH'PERMIT �+� v <br /> COMPLETE INT (PLICATE t WATER QUALITY. � .V:q!, <br /> T IDA UIN L�A �. ,+:�t -s cit t��` .. •.. t <br /> Application isherebymadetotheSarl�io L�pts a District for a permit toconstruotand/or install thework herein described.This application is <br /> made in compliance with San Joaquin ounty, r mance No.1862 a the rules and regulations of the San Joaquin Local Health District.. <br /> .. .>. <br /> Exact Slte Address � `4` �c�� /� City/Town <br /> �d..nXrva.e�i. 1 ,9.�X` �r 1•;� Pho•ne. 3 '"_ —�" zI . <br /> � <br /> Owner's Name <br /> Address pbCL� (f( <br /> -Ir-. <br /> r <br /> Contractor's Name _'"License# Business Phone ,6 X.4� <br /> Contractor's Address �' ` '' • <br /> ,.: Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes ✓ No _ <br /> k TYPE OF'WORK (CHECK}: , NEW'WELL❑ DEEPEN ❑ -RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ •WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR LY <br /> REPLACLMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines —Pit Privy . <br /> Sewage Disposal Field ................................... Cesspool/Seepage Pit ...:... _._. Other <br /> Property Line Private Domestic Welli_-_-.P6blie Domestic Well.... <br /> t INTENDED USE r_ _:-_TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Di .of Well Casing <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Gage of Casing <br /> Cr IRRIGATION 11 GRAVEL PACK Deth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Ty of Grout <br /> ❑ DISPOSAL ❑ OTHER <br /> Ot er Information..... .__........ <br /> _.._._ - <br /> 0 GEOPHYSICAL- gl face•Seal Installed 8y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump._......—L..___.. H.P. 7 <br /> PUMP REPLACEMENT: ❑ State Work•Done <br /> PUMP REPAIR: State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter l Approximate Depth <br /> Describe Material and Procedu`e <br /> ' I hereby certify that I have prepared this application andA atnhe rk will be done in accordance with San Joaquin Coui11y J <br /> ordinances,state laws,and rules and regulations of the oara`J quin Local Health District. <br /> Home owner or licensed agent's signature certifies the foil o/Vy/ing:"1 certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such f4iannler"s to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signat re cet logs the following:•'I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ,person ubjed o''workman's compepsation laws of California." <br /> I' I w cafl for,-a Grout 1 piectlOn' idr toy `Ing and a final Insp ctlPn. <br /> ?f' <br /> Signed X ' Daie: �- <br /> \� _ _ _v <br /> ( w Plot Plan on Reversedej <br /> y <br /> FOR DEPARTMENT 6S E?ONLY <br /> PHASE <br /> Application Accepted By ��� ' �' I Date <br /> Additional Comments: " - ---- - -- - <br /> Phase II Grout Inspection `%/ ll Final Inspection v'L <br /> I 'Inspection By- ' - - Date Inspection•By< <!�X1%0'' Date <br /> Fee I$Due:❑'AMNUALLY j ❑ PtR UNIT ❑ PER SITE ❑ EACH -January 1 d Receivoyianjillll ❑ July 1 R Rece"b By July 31 <br /> _ _._.. <br /> i REMIT <br /> tBILLING REMIITTANCE $ <br /> 1 'BASE EXPLANATION ! DAT hATE RE I AMOUNT nUE CHECKED <br /> ` D <br /> AMOUNT <br /> tl FEE <br /> LESS <br /> PRORATION <br /> F .... ....._.._.___.....��_._.... <br /> PLOS - _ — --- . <br /> PENALTY <br /> OilHER <br /> ! t <br /> OTHER l .. 4: •`q' .YT�. ._ _ , <br /> Received by - Date Receipt No. Permil 440. lssuartW Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20011 STOCKTON.CA 95201 <br />