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�T Applications Will Be Processed When Submitted ProperlyComPK4e1 <br /> A APPLICATfO �t t`_ Lyj <br /> i FOR OFFICE USE: - <br /> ;- (Far Non-Transferable,Revoc I1 ,;Suspendable) P&WELL <br /> I ENVIRONMENTAL HE MR,�I1251981 <br /> W WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) perm NndVor']1Qal1IAe ru r�C l rein described.This app <br /> Application is hereby made to the San Joaquin Local HealthDistrictfora ermittocons ^Y <br /> �- } r <br /> made in compliance with San Joaquin_County Ordinance No. 1862 and the rules and rdgAil;3fiiRrsi of dear oejuln Local Health District. ' <br /> City/Town <br /> Exact Site Address 3 A 3 <br /> Phone" <br /> Owner's NameCity <br /> Addressrt / <br /> Contractor's Name `License Business Phone V� <br /> ;' "*€mergency Phone <br /> l Contractor's Address Yes G__1 No _ �- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? <br /> TYPE OF WORK (CHECK): .—NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL•ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ 'r' <br /> Sewer' Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> t Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> j ❑ CABLE TOOL I Dia. of Well Excavation <br /> ❑ INDUSTRIAL <br /> ❑ DRILLED I Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE Gauge of Casing f <br /> ❑ DOMESTIC/PUBLIC d` 11 DRIVEN <br /> M'IRRIGATIO_N ❑ GRAVEL PACK I Depth of Grout Seal <br /> 3 <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC-PROTECT-I.ON_" Other information <br /> . . <br /> ❑ OTHER j 9 <br /> ❑ DISPOSAL _ Surface Seal Installed By: <br /> ❑,,GEOPHYSICAL <br /> r1 <br /> PUMP INSTALLATION::: r Contractor ' ' H.P. <br /> r Type_of Pump <br /> PUMP REPLACEMENT:-' F• ,0 State Work Done ) -0 <br /> estate Work Done <br /> PUMP REPAIR: <br /> DE5TRUCTION­OF_WEC `- �°Wel1`Diameter i <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San-Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. for which this permit <br /> ,. <br /> i Home owner or licensed agent's signature_certifies the following:"I certify that in the performance of the work <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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhichthis <br /> permit is issued, I shall employ persons subject to workman s compensation laws of California." � <br /> I i call t r a Grout I epection prior 1 grouting and a'iinal Inspection. <br /> Date- ! <br /> ' �,�� � - <br /> Signed X <br /> `" ` (Draw Plot>Ian on Reverse e) <br /> FPt DEPARTMENT USE ONLY z.. <br /> PHASE I - -� '' <br /> ( „��. ®11 <br /> Date <br /> Application Accepted By <br /> FAdditional Comments: ! e III Final InspectioPh s it Grout Inspection InspectionBDate Inspection BAptW/L Date <br /> July 1 Receiveduly 31 <br /> 'Fee Is Due: C1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ & EMIT <br /> BILLIPIG REMITTANCES - AMOUNT OU E CHECKED <br /> BASE- EXPLANATIONUAIE DATE REMITTED } AMOUNT <br /> FEE <br /> LESS .. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> te Da e. ..Mail d Delivered <br /> Received by Date <br /> Receipt NO. Permit No. - •Iss an _ - <br /> 1601 E.HAZELTON AVE.,P.O.Bos 1009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />