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-. =_- .C! Y n b Propeny <br /> : r pplicatio s R �c se ,CA,r�QN <br /> FOR OFFICE USE: c(Fo�r 1Noon�-Tran tars le, Revocable,5uspenda6le) PUMP&WELL <br /> J U L `�IVtRt9NMENTAL HEALTH PERMIT 1 <br /> 9WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) SAN JQ1� 1 l hi �St��"'f rapermittoconstruct and/or install thew ork herein described.This application is <br /> Application is hereby made to the San J "1 <br /> City/Town <br /> made in compliance wit San Joaquin unty,Ordinance o'`T'$ 2 and the rules and regulations of the Sa oaquin Local Health District. C <br /> Exact Site Address phone 1 <br /> Owner's Name City <br /> Address ZSJLHD? <br /> ense Business Phone pCl <br /> Contractor's Name Emergency Phone <br /> Contractor's Address &.-/ No <br /> is Certificate of Workman's Compensation Insurance on File❑WithRECON DESTRUCTION❑ <br /> WELL <br /> TYPE OF WORK (CHECK): NEW W€ ❑ DEEPEN <br /> I WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION❑ PUMP REPAIR <br /> I REPLACEMENTW Sewer Lines Pit Privy <br /> esspool/Seepage Pit Other <br /> DISTANCE TO NEAREST: Septic Tank C <br /> k Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> I A <br /> INTENDED USE TYPE OFWELL - Dia'of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL ` <br /> ❑ DRILLED ! Dia. of Well Casing <br /> LLED <br /> ❑ DOMESTIC/PRIVATE 13 DRIGauge of Casing <br /> ❑ DOMESTIC/PUBLIC 11 GRAVEL PACK Depth of Grout Seal <br /> [I IRRIGATION 13 ROTARY Type of Grout i <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other information <br /> I ❑ DISPOSAL face Seal Instalied By: <br /> ❑ GEOPHYSICAL _. <br /> PUMP INSTALLATION: Contractor _ �__aH.P <br /> to <br /> Type of Pump <br /> State Work Done r. <br /> i PUMP REPLACEMENT: f <br /> PUMP REPAIR: f` : ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: ' Well Diameter <br /> Describe Mate Ir al and Procedure <br /> thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ealth District <br /> ordinances, state laws, and rules anature certifiesothe following:f the San "I certify fo thlat�n the performance of the work for which this permit <br /> ,, y <br /> Home owner or licensed agent's sig <br /> is issued, I shall not employ any person ins 'c certifies ortas following. I certify thao becorne subject to t iionrthe perfo me ce.of thew <br /> Contractor's <br /> for waws of hich this <br /> I <br /> Contractor's hiring or sub-contracting signature <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> tion prior to gr utirig;and a final inspection. /]/(� Q <br /> 1 I all f r a Grau Ins <br /> �� Date: / o T <br /> Title: <br /> Signed X - - _ Gy.�praw Plot Plan on Rever�Side) <br /> #-- <br /> I C F R DEP RTMENT E ONLY <br /> PHASE 1 ; Date <br /> I Application Accepted By . <br /> ' Additional Comments. P II Final I ection <br /> Phase it Grout Inspection J <br /> J //�„ inspection By�✓ Date G Q <br /> Inspection By Date Ltd - <br /> F 31 <br /> �r REMIT <br /> Fee Is Due: ❑ ANNUALLY, ❑ PER UNIT t,a PER SITE ❑ EACH ❑ January 1 A Received 6y January 35AMOt�JDUE &Rece�CHECKEDed By y <br /> BILLING REMITTANCE <br /> BASE <br /> EXPLANATt N i DATE DATE REMITTED AMOUNT <br /> I` <br /> r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ER <br /> Irk. <br /> Receipt Nu. Permit No. <br /> Issuance ate Malted Delivered <br /> .»}Y - Date - 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKT.ON,GA 95201 <br /> URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />