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a w ali- <br />s. r hen Submitted Properly Completed, tie sure t' <br />ons Will Be Processed W • -+ ri , <br />Appl <br />APPLICATION <br />'& <br />FOR ZFFICE USE: <br />(For Non -Transferable, Revocable,` Suspendable) PUMP WELL <br />_•� <br />HEALTH PERMIT <br />ENVIRONMENTAL <br />WATER QUALITY .. . —.f .., sr .- !f,. _ - — <br />riictt..Ilcationls <br />IN TRIPLICATE) for a <br />Iulesandregulatdionsoftthlthe wor <br />eSan. quinlLocal HeathTDistrhis <br />(COMPLETE <br />NO <br />made in compliance h n oa uin Count y rd' a <br />City/Town - <br />1, ♦♦ er^' i <br />'Exact Site Addres n 177 �► Ar <br />phoe <br />PIS <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 ❑,-,_ <br />NEW WELL 13DEEPEN ❑ " RECONDITION ❑ DESTRUCTION PUMP REPAIR ❑ <br />N <br />TYPE OF WORK (CHECK): <br />ABANDONMENT 13 OTHER 11 PUMP W57ALLATIO <br />WELL CHLORINATION 11 WELL <br />REPLACEMENT❑ Sewer Lines Pit Privy <br />µ Septic Tank Other <br />DISTANCE TO NEAREST: Cesspool/Seepage Pit <br />Sewage Disposal Field Public Domestic Well <br />Property Line Private Domestic Well <br />TYPE OF WELL <br />INTENDED USE t Dia. of Well Excavation <br />j <br />V ❑ INDUSTRIAL ❑ CABLE TOOL <br />13 DRILLED Dia. of Well Casing <br />��{{ <br />G CXDOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br />❑ DOMESTIC/PUBLIC ❑ GRAVEL PACKDepth of Grout Seal <br />❑ IRRIGATION ❑ ROTARY Type of Grout <br />Information <br />p ❑ CATHODIC PROTECTION ❑ OTHER <br />---Other <br />13 DISPOSAL. Seal Installed. By: " <br />�Sura <br />❑ GEOPHYSICAL! <br />I Contractor H.P. <br />PUMP INSTALLATION: Yype <br />of Pump <br />o� <br />PUMP REPLACEMENT: ❑- State Work Done <br />❑ State Work Doney <br />I PUMP REPAIR: Approximate Depth <br />F WELL: Well Diameter <br />DESTRUCTION OF <br />Describe Material and.Procedwe <br />. <br />he work llHealtbe in ccordance with San Joaquin County <br />k hereby certify that I have prepared this application he San Joaquin Local h Districtone <br />state laws, and rules and regulations <br />in the <br />C <br />ordinances, y that performa <br />Home owner or licensed agent's signature certi such mannerties the as togbelcomefsubject to workman's compensation laws of California." <br />the work forwhich this <br />' is issued, I shall not employ any person <br />certifies the following: "1 certify that in the performance of <br />I Contractor's hiring or sub -contracting signature <br />to workman's compensation laws of California." <br />per is issued, I shall employ persons subject <br />I to and a final inspects R swow <br />I will call for a Grout inspection prior grouting <br />Date: Ile <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 />Additional Comments' } � I <br />ha' na spection �3� <br />t' Phase II Grout Inspection Inspection By Date <br />Date <br />lnspecti6n By <br />❑ EACH ❑ January 1 &Receive$ By January 3t uly I & ReceICµEMIT By July ' 31 <br />l REMIT <br />Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' <br />-- REM4TTANGE AMOUNTDOE' <br />AMOUNT <br />_ .BILLING <br />- BASE -EXPLANATION- DATE - DATE' REMITTED <br />r <br />FEE <br />-LESS_ t T <br />PRORATION - <br />PLUS <br />PENALTY- <br />ENALTYOTHER <br />OTHER <br />OTHER F �. 4- - .. <br />' Mailed' Delivered: <br />' <br />Issua ce.D ie <br />.. <br />Receipt No, �.•- — Permit Nor � -CA 95201 <br />' -- 2609 5TOCKTON, <br />'- Received by - -� ---�-- Date • ^- 1601 E. HAZELTON AVE., P.O. Box <br />HEALTH PERMITI5ERVICES <br />APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL <br />- <br />