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Applications Will Be Processed When Submitted PropePly omp <br /> APPLICATION <br /> FOR OFFICE USE: �� (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> Co ENVIRONMENTAL HEALTH PFRMiT <br /> (COMPLETE IN TRIPLICATE) �� S- '"' .P1J <br /> WATER QUALITY C o 3 - This`-t b <br /> hereby made to the San JoaquinLocalHealthDistrictforapermrutlesond reguI tnstruct dions ofall the work the San Joaquinln describe <br /> Local.Heallth District. Is <br /> Application is he y - <br /> made in compliance with San Joa wn County Ord nance No.iSfi�and the <br /> A City/Town <br /> !, ,, W <br /> Exact Site Address <br /> �0�• � Phone <br /> CityF 17.4 <br /> Owner's Name <br /> Address D rr 61 �r�icense# j.y <br /> Business Phone <br /> L <br /> Contractor's Name )041 Q(., .,Emergency Phone! 1 <br /> G t� '�`� No �- <br /> Contractor's Address „HD? Yes _ =• <br /> Is Certificate of Workman's Gompensatian Insurance on File❑ RECONDITION❑ DESTRUCTION❑- <br /> TYPE OF WORK`(CHECK): NEW WELL❑` -DEEPENON <br /> �Q <br /> WELL F W CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION❑ PUMP REPAIR <br /> Li <br /> REPLACEMENT 11Sewer Lines pit Privy <br /> Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well r <br /> TYPE OF WELL <br /> INTENDED USE ❑ CABLE.TOOL Dia. of Well Excavation <br /> 1 ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> I ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> 5& IRRIGATION 13 GRAVEL PACK Type of Grout .� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ' ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: r Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: A'® � - <br /> State Work Done - � -Approximate Depth <br /> PUMP REPAIR: Well Diameter <br /> DESTRUCTION OF WELL: <br /> ;Describe Material and Procedure • <br /> t _ <br /> ' 1 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. <br /> g:" <br /> manner as to become subject to workman's compensation laws of California." <br /> Home owner or licensed agent's signature certifies the following: L certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such <br /> Contractor's hiring or§ub-contracting signature certifies the following'."I certify that in the performance of the work tot which this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout Inspecti pri r to grog an tinaf inspection._ } <br /> Date: <br /> tle: <br /> Signed (Draw Plot n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> ' hase III Final I pectio� �� <br /> Additional Comments: r. <br /> Phase 11 Grout Inspection Date <br /> I Date Inspection By ' <br /> Inspection.By Jul 1 &Received By July 31 <br /> ❑ EACH ❑ January 1 &Received BY January 31 ❑ Y REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER 517E $ AMOUNT DUE CHECKED <br /> BILLING - REMITTANCE REMITTED AMOUNT <br /> IF BASE <br /> EXPLANATION DATE DATE <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY y <br /> OTHER <br /> OTHER y <br /> Mailed Delivered .- - <br /> Permit No. Is uance ate <br /> _ Received by <br /> Date Receipt No. t601 F.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />