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M <br /> Applications WIII Be Processed <br /> a Y,.-� <br /> APPLICATION 11 <br /> When Submitted ProperlyCompleted. <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> + ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ;23-75- S. application is <br /> Application is hereby made to the San Joaquin Local ance NDistrict for a permit to o. 1862 and the rules and regulasfruct tions ofthe San Joaquin Local Heath District. <br /> made In compliance with San Joaquin Gou y Lel _ �, .'Ll,A e City/Town L <br /> Exact Site Address I? £l. /O III �rr�c. .r r 10 <br /> Phone i <br /> Owner's Name L- City—L <br /> /2 rJ, VIS <br /> License# Business Phon <br /> Address e <br /> Contractor's Name purviance Drillers <br /> Dri Ing Corp. <br /> ' w r(/ _ .: fc .� Emergency Phone I <br />`'; Co�itra�ctor's Address No <br /> L_HD? Yes <br /> is CertiticAte of Workman's Compensation Insurance on File With SRECONDITION❑ DESTRUCTION❑ <br /> Ems'""TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN <br /> T ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> WELL CHLORINATION 11 WELL ABANDONMEN <br /> I <br /> REPLACEM_ ENTM, Pit Privy <br /> DISTANCE TSewer Lines <br /> O NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ► <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> r ❑ INI]USTRiAL ; <br /> ❑'DRILLED `Dia.of Well,Casing <br /> 1:1DOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> P4 IRRIGATION 11 ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> 1.1 DISPOSAL Sur��ace 5Lea1 Installed By! <br /> ❑ GEOPHYSICAL i pgryiance Drillers n Ing or"p• <br /> PUMP INSTALLATION: Contractor H P <br /> tType of Pump Y b 1 <br /> PUMP REPLACEMENT: ® State Work Done x ; <br /> 4c:--State Work Done <br /> PUMP REPAIR: :;-_ <br /> % " Approximate Depth <br /> 4_ <br /> OF WELL: Well Diameter Lill <br /> DFESTRU,&� <br /> Describe Material and Procedure " <br /> v <br /> 1 <br /> hereb 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 /> 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 any person in such manner as to become subject to workman's compensation laws of California.' <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Gr spection prior to grouting and a final inspection. rs <br /> f v rG�Si� -r Dale:. <br /> Title:' <br /> Signed X • . '- (prow Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 i Date <br /> ApplicationAcceptedBy <br /> Additional Comments: p e I Final inspection * f <br /> Phase 11 Grout Inspection Date <br /> inspection By <br /> Date Inspection By <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Sanuar m 1 &Received 8y July 31 <br /> y <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> _ \ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> f <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> .OTHER <br /> i <br /> r'`• Delivered <br /> I suance.Pate Mailed <br /> ` Receipt No. Permit No,, 1, '^ „, t.s. CA 95201 <br /> Received by Da } "' 0 .1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON, <br /> APPLICANT-RETURN ALL COPIES NO: � ENVIRONMENTAL HEALTH PERMITISERVICES ��„•w,•,,.,' <br />