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_�— <br /> Applications Will Be Processed When Submitted <br /> APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable, Revocable,Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F. _ , .: WATER QUALITY Z— p —OS <br /> (COMPLETE IN TRIPLICATE) _e , <br /> his <br /> all the work In <br /> k <br /> Application is hereby made to the an Joaquin Local Health Districtf a dpermit uses construct nd regulations oftthe San Joaquin Local HealdthTDistapplicaUon Is <br /> made in compliance with San Joaquin County Ordin ce No. 186 City/Town <br /> _ Exact Site Address t _ Phone 62 <br /> Owner's Name City 9 <br /> Address License# n7��8Business Phone <br /> Contractor's Name Emergency Phone <br /> ! Contractor's Address ✓ No — <br /> Is Certificate of Workman's Compensation Insurance on File With SRECONDITION❑ DESTRUCTION❑ <br /> P REPAIR 13 <br /> TYPE OF WORK (CHECK)'. NEW WELL DEEPEN <br /> f OIVMEiT ❑ 1:1OTHER PUMP INSTALLATION❑ PUM <br /> WELL CHLORINATION El WELL ABAND .,r <br /> REPLACEMENT C3 Q 'J< Sewer Lines Pit Privy 4� <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other b <br /> Sewage Disposal Field YO — Public Domestic Well <br /> 1' Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL pia. of Well Excavation �� P <br /> k <br /> INDUSTRIAL ❑ CABLE TOOL l <br /> ❑ DRILLED Dia. of Well Casing <br /> '-' .'DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ,❑ pOMESTIC/PUBLIC <br /> k <br /> GRAVEL PACK <br /> IRRIGATION Depth of Grout Seal <br /> ROTARY Type of Grout � <br /> ❑ CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL ❑ OTHER <br /> Surface Seal Installed By: <br /> 1 ❑ GEOPHYSICAL <br /> Contractor H P <br /> PUMP INSTALLATION: Type of Pump <br /> r ❑ State Work Done <br /> (` PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> I <br /> DESTRUCTION OF WELL Well Diameter <br /> a Describe Material and Procedure <br /> I hereby certify that 1 have prepared this ill be done in accordance with San Joaquin County <br /> application and that the work w <br /> I ordinances, state flaws, and rules and regulations of the San Joaquin Local Health District, <br /> for this permit <br /> Home owner Or licensed agent's signature certifies the following:°1 certify that in the performance of the work <br /> is issued, 1 shall not employ.any person in such manner as to become subject to workman's compensation laws of California." <br /> e work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of th <br /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I call for a Grout In tion prior to routing and a finan. Date: <br /> r A2-- <br /> THAW. L <br /> -0-7 <br /> Signed X raw Plot Plan Side) <br /> I FOR DEPARTMENT USE ONLY <br /> l 4 -Its-a?-. <br /> PHASE 1 0 � ©V Date <br /> Application Accepted By <br /> i Additional Comments: In ection D <br /> Phase 11 Grout Inspection Inspection y Date <br /> Inspection By Date <br /> C3 Juiy 1 &Received y 91 <br /> t Fee is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH January 1 & eceiveREMIT <br /> d By January 31 CHECKED <br /> ❑ <br /> BIL $ <br /> LING REMITTANCE AMOUNT DUE AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> L <br /> FEE kAl <br /> l <br /> LESS <br /> PRORATION I - <br /> PLUS <br /> PENALTY <br /> F y Y <br /> OTHER 4 � <br /> i <br /> OTHER _ <br /> 1�' Mailed Delivered <br /> Receipt NoPermit No, Issuance ate <br /> ate,, Rec , S70CKTON,CA 95201 <br /> Receive y' - 1801 E.HAZELTON AVE.,P.O.Box 2009 <br /> APP CANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />