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yCo <br /> —FOR OSI FICE USE: I Be Prptc hen e� properly Co d. Be pure p Sp e A <br /> ',1 r,N.1- APPLICATION PdMV � f � tion .,.-_ <br /> ransierable, Revocable, Susperodabie} f 7 Na ? <br /> IRONMENTAL HEALTH 1 n,AQUIN LOCAL PUMP&WELL I <br /> (COMPLETE IN TRIPLICATE} �1EP> WATER QUALITY LTH DISTRICT `•h r t <br /> Application is hereby made to the San Jo ui$$$� a <br /> made in compliance it n Jo uin q Ith istri forape str /oriristallthework herein described.This application is I <br /> Ca�l`bn es o a, HCCit ;��"o t ne �e l�da r �s of the San Joaquin Local Health District. <br /> Exact Site Address Ike e ct. + <br /> S e O el e e 1S aYl Y �ity/Town <br /> Owner's Name F�^a -bu <br /> Address Phone <br /> Contractor's Name - City T—rl <br /> Contractor's AddressLicense 4g29Q - Business Phone - <br /> 'I <br /> is Certificate of Workman's Compensation IEmergency Phone <br /> nsurance on File With SJLHD? Yes=_X_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ \ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT El PUMP INSTALLATION PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Other <br /> private Domestic Well <br /> INTENDED USE Public Domestic Well <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation � <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION ❑ GRAVEL PACKn <br /> 11 Depth of Grout Seal <br /> CATHODIC PROTECTION 1:1 ROTARY <br /> ❑ DISPOSAL ❑ OTHER Type of Grout <br /> ❑ GEOPHYSICAL Other Information U <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> C �r <br /> ontractor St Pum <br /> Type of Pump �I . <br /> PUMP REPLACEMENT: ❑ State Work Done H P ` <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth r <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. -5.. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ an {p f <br /> P Y Y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California. <br /> -contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> 1 vy,111 call for a Grout Inspection prior to grouting and a final inspection. 1 <br /> Signed X L`� }+� ' <br /> ~ Title: _ Date: <br /> (Draw Plot Plan on Reverse Side) , <br /> FOR DEP RTMENT SE ONLY <br /> PHASE 1 <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase Il Grout Inspection i <br /> Kase II Final Inspection <br /> Inspection By Date Inspection By Date —zz-�z <br /> Fee Is. Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACHn <br /> ❑ January 1 &Received By January 31 © July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT j <br /> DATE DATE REMITTED AMOUNT DUE CHECKED } <br /> EEE <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Received by - Date <br /> Receipt No. Permit No, Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIIYSERVICES Delivered <br /> - 160 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 / <br />