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. _ r� wV v <br /> Applications Will,Be Processed When Submitted Properly omp <br /> 1 APPUCAT10N <br /> FOR,QUSE: (for Non-Transferable, Revocable, Suspendable) PUMP&d ELL � <br /> - ENVIRONMENTAL HEALTHPERMIT <br /> r <br /> TER QUALITY stru, ' S �' �� �- <br /> �'7`f5 0 <br /> {COMPLETE IN TRIPLICATE) 7 <br /> Application is hereby made to the San Joaquin Local Health Dist18 t for andtherules and reguI-antons oftthe San Joaquip e work.herein Local Health DistThis rict. <br /> Ion I <br /> PP <br /> made in co liance wit San Joaquin County Ordinanc No f- City/Town <br /> Exact Site Address Phone 3G 6=11i::'! " <br /> d Ir <br /> Owner's Name �\ ��� 7 City d f <br /> Address �, L J Business Phone <br /> a �. License#� <br /> Contractor's Name �:�. [. Emergency Phone i <br /> Contractor's Addl Yes No _ I <br /> Insurance on File With SJLHD. ❑ .4 <br /> is Certificate of Workman's Compensation �EEPEN ❑ ` RECONDITION❑ ,DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 3 <br /> REPLACEMENT❑ �g Sewer Lines & Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank /�-J - Other <br /> Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well Y <br /> TYPE OF WELL r. <br /> INTENDED USE Dia. of Well Excavation/ <br /> I <br /> 13 INDUSTRIAL <br /> BLE TOOL <br /> 13 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing l <br /> ❑ PUBLIC Depth of Grout Seal ( h} <br /> ❑ GRAVEL PACK <br /> gfCASTJ�CPROTECTION <br /> Type of Grout <br /> ❑ ❑ ROTARY h <br /> ` ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL F {?1 <br /> f PUMP INSTALLATION: Contractor H p <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Well Diameter Approximate Depth <br /> }. DESTRUCTION OF WELL: <br /> ' <br /> Describe Material and Procedure <br /> 1 { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> th District. <br /> k <br /> ordinances, state laws, and rules and regulations of the San Jo aq certif than Local t ntlheperfo manceoftheworkforwhichthispermit <br /> I Home owner or licensed agent's signature certifies the following:` Y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California. <br /> R <br /> Contractor's hiring orsub-contrang:"I certify that in the performance of the work forwhich this <br /> cting signature certifies the followi <br /> persons subject to workman's compensation laws of California." <br /> permit is issued, I shall employ p r <br /> I will call for a Gr ut Inspection prior 10 grouting and a final inspection- iµ .a Date, <br /> Title: J <br /> " Sig`ne� Plan on Reverse Side) <br /> X r (Draw Plot <br /> l ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q Date <br /> Application Accepted By <br /> Additional Comments: .. a 41 Final Inspection <br /> Phase it Gro t I s ectill By <br /> Inspection Dat <br /> to <br /> Inspection By <br /> { ❑-PER SITE '❑ EACH� ❑ January 5 &Received By'January 31 ❑ July 1 S ReceivedREM47�ly 31 <br /> Feeds Due: ❑ ANNUALLY ❑ PER UNIT $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> I BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER c r� <br /> p� Mailed Delivered <br /> ate r Receipt No_ , <br /> Permit No. - 1ss anc Date <br /> Received y 1601 E.HAZELTON AVE.,P.O-9aa 2009 STOCKTRN,CA 95201 <br /> APPLICANT—RETURN ALL COPIES T. ENVIRONMENTAL HEALTH PERMITISERVICES <br />