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Applications Will Be Processed When Submitted Properlycompieltea.wez)uru 1 o1i <br /> f ' <br /> FOR OFFICE USE: APPLICATION <br /> � <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> �.0 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY , <br /> (COMPLETE IN TRIPLICATE) 1 <br /> lA plication is hereby made to the San JoaquinLocalHealthDistrictforapermittocanstructaadloos oftheSan JoaquinlLoc%I Heal This is 1 <br /> P <br /> made in compliance wiri <br /> San Joaquin County Or mance No. i8 a the rules and regu City/Town <br /> Exact Site Address <br /> Phone �s <br /> Owner's Name City C <br /> Address t License Business Phone , <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _— , <br /> TYPE OF WORK (CHECK)El <br /> W�LL�ABANELL IDONMENT ❑DEEPEN ❑ RECOTHERO❑ ITI ❑P INSDTALLATIOIN� PUMP REPAIR C3 i <br /> WELL CHLORINATION <br /> REPLACEMENT❑ l <br /> �- Sewer Lines /! Plt Pdivy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Cesspool/Seep_age_Plt' _ Oth2; <br /> Sewage_Dsposal_F-Field. �_ <br /> Public Domestic Well a <br /> Property Line JS�Private Domestic Well� _ . Y <br /> INTENDED USE t_ TYPE OF WELL - � � .� ,,.` . t <br /> OI pia. of Well Excavation <br /> ❑ INDUSTRIAL ^CABLE TOOL <br /> -- __ 0 ❑ DRILLED Dia. of Well Casing <br /> ti .DOMESTIC/PRIVAT.E ❑ DRIVEN Gauge of Casing <br /> x - <br /> '❑.DOMESTIC/PUBLIC."_ '� f" y ` <br /> ' ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ❑ ROTARY Type of Grout � � � <br /> ❑ CATHODIC PROTECTION <br /> ❑ OTHER Other Information 3 <br /> ❑ DISPOSAL �i <br /> ❑ GEOPHYSICS Surface Seal, By: <br /> „.r__ z f f <br /> k �* <br /> k � � Contractor <br /> PUMP INSTALLATION: t <br /> H.P. <br /> 9 Type of Pump � l <br /> ❑ State o <br /> PUMP REPLA'E M NT: ` Work Done <br /> ! t <br /> PUMP REPAIR ❑ State Work Done <br /> Approximate Depth 1 <br /> DESTRUCTION OF WELL: Well Diameter i <br /> Describe Material and Procedure <br /> f ion and that the work will be done in accordance with San Joaquin County <br /> ared this application _ <br /> I hereby certify that I have prep P " <br /> (ordinances, state laws, and rules and regulations of than Joa= uLoca�-Health District, y ' <br /> Home owner or licensed agent's lige Bonen such mannerlas+togbecomte subject to wy that 1h —e orkman's as cmpensationf laws of California."r which this l <br /> ris issued, I sFiall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following:'9 certify that in the performance of thew k for which this <br /> . permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> w�ii all for a Grout spec on prior-to grouting and a iirial��ection. <br /> t �e-�Pt Tiife. _`1 r. Date: <br /> Signed X -- � <br /> ""(Draw Plot Plan oh ReverseJSide)� <br /> M FOR DEPARTMENT USE_ONL ry�� } <br /> FApplication <br /> � � 'Date <br /> Accepted By <br /> al Comments: a,* ' ` n <br /> P s II Final 1 pectinn <br /> Phase GroutAlectia " Datea-t�/_tf <br /> inspection By r. <br /> Inspectlon;By ate> = <br /> f!/y/ <br /> Fee Is Dine: ❑ A�N _ LL ❑ PER UNIT ❑ PER SITE. ❑ EACH ❑ January I &Received By January 31 ❑ July ReceiveRdEB�ITuIy 31 y <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> YY <br /> LESS A R <br /> PRORAT4ON '�.. <br /> t� <br /> PLUS �� s <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ __ Receipt No.~'' Permit No. is uence Date Mailed,.. Delivered <br /> Receivedby Date F <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMITISERYICES <br /> 1807 E.HAZELTON AVE.,P.O.Box 2009 S70CKTON,CA 95201 P <br />