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T '' i eb` t§t]Nieraes `5 Submitte( rropv�ry + <br /> PLIJL� <br /> *i APPLICATION <br /> FOR OFFICE USE: l i�p or Non-Translerable,Revocable,Suspendable) PUMP&WELL : r <br /> . 0CT2 � 1O t <br /> C �NVIRONMENTAL HEALTH PERMIT t <br /> f�77-7S'-"6 CQCA�. WATER QUALITY �o- aS application is <br /> yAJ f>�r Q �j�ja� <br /> (COMPLETE IN TRIPLICAT hDistrictforapermit toconstructand/orinstallthework.hel�LLocal Hea�hTDisthis t. <br />` Application is hereby made totlwaxi-'Aui <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and egul do of theSan Joaq r <br /> Exact Site Address , Phone <br /> Owner's Name City <br /> Address License# ��-�rsiness Pho e <br /> Contractor's Name ` Emergency Phone 1 <br /> I No <br /> Contractor's Address !,, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? esDESTRUCTiONCI V i <br /> 11 TYPE OF WORK (CHECK): NEW WELL DEEPErN 13 OTHE OO Ili P mP INSTALLATION❑ PUMP REPAIR❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT <br /> Pit Privy <br /> ( tic TanSewer Lines <br /> REPLACEMENT 1 Other <br /> DISTANCE TO NEAREST: Sep k Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> _ . _ TYPE OF WELL,.._. <br /> INTENDED USE . " <br /> Dia. of Well Excavation <br /> C3CA13LE TOOL <br /> 11 -INDUSTRIAL - 0 DRILLED Dia. of Well Casing <br /> C -❑ DOMESTIC/PRIVATE Gauge of Casing <br /> t <br /> I C3 ❑ DRIVEN DOMESTIC/PUBLIC i C3 GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ IRRIGATION ! 13 ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ` ❑ DISPOSAL Surface Seal installed By: 1 <br /> L ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I/ Approximate Depth <br /> Well Diameter 3 Qh r • <br /> f c a <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure � <br /> pO <br /> I hereby certify that I have prep Id this application <br /> the San Joaquinhework will <br /> al bedone District,accordance with San Joaquin County (� <br /> ordinances, state laws, and rules and regulationslcertifythatintheperformanloftheworkforwhichthispermit €^ <br /> Home owner or licensed agent's signature certifies the following:' ?r <br /> is issued, I shall not employ any person in such manner <br /> the following:to `'I certify hact to st in the peas sfoormance of he work for wh ch this l <br /> k <br /> Contractor's hiring or sub-contracting signature certifies 1 <br /> permit is issued, I shall employ persons subject to workman;s compensation taws of California-" <br /> I will all f a Grout spection prior to grouting and a final inspection. <br /> } Date: <br /> Title: <br /> t Signed X (Draw Plot Plan on Reverse Side) ` <br /> FI <br /> ij•, - <br /> —FOR DEPARTMENT USE ONLY f <br /> PHASE I \ Date t <br /> Application Accepted By I <br /> Additional Comments: Phase 111 Final Inspection <br /> k Phase Il Grout Inspection C7.3— Date <br /> Date Inspection By <br /> Inspection By `; <br /> El ❑ January 1 R Received By January 31 ❑ July 1 R Received 13�I�uiy 31 <br /> U <br /> Fee IS Due: ❑ ANNUALLY ❑ PER NIT ❑ PER SITE ' REMITTANCE $ AMOUNT DISE CHECKED <br /> BILLING REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> ' FEE O o <br /> LESS <br /> PRORATION <br /> PLUS . <br /> E PENALTY <br /> OTHER j <br /> OTHER lk` <br /> Receipt No. Pe mit No. <br /> Issu nce Date Mailed Delivered <br /> Received by Date 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON, <br /> CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES - - <br />