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s. r hen Submitted Properly Completed, tie sure y <br /> awall - <br /> Appl ons Will Be Processed W • -+ ri <br /> APPLICATION <br /> FOR ZFFICE USE: (For Non-Transferable,Revocable,`Suspendable) PUMP'&WELL <br /> _•� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY .. . —.f . ., sr .- If,. - <br /> (COMPLETE IN TRIPLICATE) for a <br /> Iulesandregulatdionsoftthlthe wor <br /> eSan. quinlLocal HeathTDistrhis riictt..Ilcationls <br /> made in compliance h n oa uin County rd11 �' a NO City/Town - ♦ <br /> 177 �► Ar <br /> 'Exact Site Addres phone <br /> Owner's NameCity .•: <br /> Address i.fE " License#` Business Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address �— No r m <br /> Is Certificate of Workman's Compensation Ins ance on File With SJLHD? Yes NDITION❑ DESTRUCTION❑��,.,_ <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPEN ❑ RECOPUMP REPAIR❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER 11 PUMP W57ALLATION <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST:µ Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> j INTENDED USE t Dia. of Well Excavation <br /> V ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ��{{ 13 DRILLED Dia. of Well Casing <br /> G CXDOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACKDepth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> p ❑ CATHODIC PROTECTION ❑ OTHER --- Other Information <br /> 13 DISPOSAL. � Sura Seal Installed.By: " <br /> I ❑ GEOPHYSICAL! <br /> Contractor H.P. <br /> PUMP INSTALLATION: Yype of Pump o� <br /> ❑-State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Doney <br /> I PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF <br /> F WELL: Well Diameter <br /> . Describe Material and.Procedwe <br /> he work k hereby certify that I have prepared this application he San Joaquin Local llHealtbe h Districtone in ccordance with San Joaquin County C <br /> 1 ordinances, state laws, and rules and regulations <br /> y that in the performa <br /> Home owner or licensed agent's signature certi such mannerties the as togbelcomefsubject to workman's compensation laws of California." <br /> ' is issued, I shall not employ any person <br /> j Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> I <br /> per is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection prior to grouting and a final inspects Date: Ile <br /> R swow <br /> Title: <br /> Signed X �,(Draw PIOt Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY a / <br /> PHASE I /i6%"`-/ Date / <br /> r <br /> Application Accepted By <br /> ha' na spection �3 � <br /> Additional Comments' } � I <br /> t' Phase II Grout Inspection Inspection By Date <br /> Date <br /> lnspecti6n By <br /> l REMIT <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH ❑ January 1 &Receive$By January 3t AMOUNTDOE <br /> uly I &ReceICµEMIT By July 31 <br /> _ -- .BILLING REMITTANCE REMITTED AMOUNT <br /> - BASE -EXPLANATION- DATE - DATE' <br /> FEE r <br /> PRORATION ` <br /> PLUS <br /> PENALTY- <br /> OTHER <br /> ENALTYOTHER <br /> OTHER F 4- - .. <br /> Mailed' Delivered: <br /> .. Issua te.D ie CA 95201 <br /> ' -- ReceiptNo. �.•- — <br /> Permit Nor � - <br /> '- Received by - -� Date• 1601 E.HAZELTON AYE.,P.O.Ba,I 2609 5TOCKTON, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITI5ERVICES - <br />