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-� Applications'Will Be Processed When Submitted Properly • 1 �. t `U` <br /> FOR AFI::",USE: <br /> -- APPLICATI( �C (u, <br /> ' (For Non-Transferable, Revoca s nib e} PUMP&WELL <br /> ENVIRONMENTAL HEAL E � 1981 <br /> ' WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) r� n+described.This application is <br /> Application is hereby made to the SanJoaquinLocalHealthDistricttorapermittoconstructa /or;rtfT!C <br /> Cry�`'� In Local Health District. <br /> made in compliance ith San Joaquin6ounty Ord. a ce No. 1862 and the and regr� ' <br /> Exact Site Add res; <br /> Phone <br /> 4/ - <br /> Owner's Name City <br /> Address — _�- � <br /> Contractor's Name License# G 2� Business Phone <br /> r <br /> Emergency Phone <br /> Contractor's Address <br /> t 1/ No r <br /> t. Is Certificate of Workman's Compensation insurance on File With SRECO Yes <br /> F TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> f <br /> WELL CHLORINATION 13 WELL. ABANDONMENT ❑ OTHER ❑ 'P-UMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT F-1 4 ,,....,�-- _.�_- -. .- - — <br /> ---�""_Sewer Ciries Pit P'r`ivy <br /> DISTANCE TO_NEAREST:- -Septic_T-ank- -' Cess oal/Seepage Pit Other <br /> T Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL _ <br /> INTENDED USE <br /> • "�� xcavation�� �... <br /> El INDUSTRIAL ❑ CABLE TOOL Dia. of Well E <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> 11 IRRIGATION I <br /> C1 GRAVEL PACK Depth.of Grout Seal <br /> 13 CATHODIC PROTECTION 11ROTARY Type of Grout <br /> ti <br /> ❑ DISPOSAL ❑ OTHER <br /> Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> f{��, a <br /> F PUMP INSTALLATION: Contractor 1� <br /> kType of Pump H.P. <br /> F -PUMP REPLACEMENT: ElState Work Done F <br /> PUMP REPAIR: �5tate Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: , Well Diameter <br /> • <br /> ti Describe Material and Procell a ' <br /> I hereby certify that I Have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tions of the San Joaquin Local Health District. <br /> ordinances, state laws, and rules and regula <br /> Homeowner 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 /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi fl f r a Grout pection prior to grouting and a final-ins ction. <br /> 'fie: <br /> `�--✓^ Date: J <br /> Signed X _ <br /> i (Draw Plot Plan on Rovers Side). �. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I��'-�- Date <br /> Application Accepted By r <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Dake Inspection By �� Date <br /> l� max. <br /> ❑ ER UNIT El PER SITE ❑ EACH C1 January 1 &Received 8y January 31 ❑ July 1 &ReceiveREMIBy Tuly 3 <br /> Fee e Is Due: 13 ANNUALLY P <br /> ON BILLING REMITTANCE '$ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED - AMOUNT <br /> tr � <br /> FEE <br /> i LESS <br /> ..: PRORATION <br /> PLUS - y. - – - = - =---�'•+• ¢' <br /> X= OENALTY~� - <br /> OTHER <br /> OTHER <br /> F <br /> 3S <br /> ,;;` Receipt No. - Permit No. Issuanc Date ,Mailed Delivered �a. <br /> Received by Date i <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 16111E.HAZELTON AVE.,P.O.Box 2D09 STDCKTON,CA 95201 -� <br />