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IN Plica 11ons Will B, "Processed When Submitted Prpperly Completed. Be Sure.To Sign The Application G <br /> FOR OFFICE USE APPLICATION <br /> r Non=Trenafeiable, RTvocable, Suspegdable) <br /> ~ PUMP&WELL . <br /> • ENV/IIRONMENTAL HEALTH PERMIT <br /> (COMPI TE IN TRIPCICATE)'it, E04/D�E T� WATER QUALITY r , <br /> Appl icaV is hereby made to the San Joagyi It Local Health'District for a permit to construct and/or install the work herein described.This applicatil is <br /> made incompliance with San J q 'Courtly Ordina�n-eNo. ]iI662and the Vrii es"and re lations the'San o Ruin Local Health�DiissMr t. <br /> Exact S?k AdIt S Y ii/�" 3�n'1J <br /> . . ;3 l 0 Phone <br /> Owner's Name ' <br /> Address .; yy:���� �_ ,�. •' City.. �32PiJ e� <br /> Contractor's Name _15/Pdi�l:r r Z License k,��J�'/ Business Phone 51 —//�5 _ <br /> Contractor's Address '' ` — Emergency Phone" Z/ 1 <br /> Is Certificate of Workman's Compeq) afion JnsVranc&on File With SJLHD? ` Yes. X 'i No W <br /> TYPE OF WORK (CHECK): NEW WELLA DEEPEN d RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION 11 WELL �PBANDONMENT OTHER ❑- PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank /00 .Sewer Lines Pit Privy - <br /> Sewage Disposal Field /00 Cesspool/Seepage Pit Other C: <br /> Property Line ' Private Domestic Well Public Domestic Well g <br /> INTENDED,USE - TYPE OF WELL <br /> _ <br /> Q INDUSTRIALCABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing , GJ � � <br /> ❑ DOMESTIC/PUBLIC, - QpAIV.EN, Gauge of Casing - /&0zy azo. <br /> 0 IRRIGATIQN GRAVEL PACK Depth of Grout Seal . . <br /> P CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL.-' <br /> OTHER Other Information. <br /> GEOPHYSICAL Surface Seal Installed By: Z4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump., H.P. r <br /> PUMP REPLACEMENT: q State Work Done— <br /> PUMP <br /> one PUMP REPAIR:- "❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well"DiaAteter• Approximate Depth <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 Joequin Local Health District. - <br /> Home owner or licensed agent'i'signature certifies the following:+'I certify that in the perfprmance of ihe'work for which this permit <br /> js issued, I shall pot employ any gersgn"in such manner as)D become spbject to workman's compensation laws of California:' <br /> Contractot s In or`aub-cpnttaCling eignature certifies the fgllowing:"I certify that In the performance Of the work for which this <br /> permit is issued,I shail'employ persons subject to Workman;s ponlpenslition laws-of California." <br /> I vQII C II for a Grdu1 InfP Ilion Ion 1p grouting and a filial inspe!-cllo�n `/�f <br /> Signed X �Mc - Title: , ! '! a /f r Date: 5 sA l <br /> (Draw PI Plan on Reverse Sidle) <br /> r( FOR OEPAIR <br /> TMENT U$E ,ONLY 1 <br /> PHASE I p "� <br /> APPlipatiori Accepted BY ""' '^ ---.-�,---. . � "Date�L a <br /> Additional Comments: <br /> P Grout inspection � ' r' Phase III Final Inspection - <br /> lnSpRctlOn By ./�_ r . - It pate . 7 1 . Inspection By T�iJ to <br /> FQe Is D4fi ❑ AN ❑ PEP UNIT ❑ PER$ITE EACH ❑ January1 06 ReceivKd By January 31. ❑ JWy 1 it Received 6y July 31 <br /> eILLIN REMITTANCE'S �f ` REMIT D <br /> "BfSE" ' EXPLANATION DATE PATE REMITTED ' 'AMQUN7 DUE AMOUNTCHECKE <br /> FEE ..�, ; , r <br /> LESS <br /> PROPATION . .•<p - <br /> PLUS <br /> PENALTY' <br /> OTHER. ,. <br /> OTHER i <br /> B5 2 ; <br /> ReceNed by D to 1. Receipt No: Permit No - Issuance Cate Malim. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 2009 STOCKTON,CA 95201 <br />