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Applications Will Be Processed When Submitted Properly Completea.wez-Ft: 1vi Q <br /> APPLICATION <br /> FOR OFFe'E USE' (For Nan-Transferable, Revocable;Suspendable) PUMP&WELL ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) e. in Local eaith District. <br /> Application is hereby made to the San Joaquin Locainan le <br /> No.1862 andphrmrutles and regulations oftthe S n Joaq rein described.pi6alt This app <br />' made in compliance wi Joa ujn Count r ci. City/Town <br /> L <br /> Exact Site Address e g <br /> f Phone <br /> Owner's Name City <br /> ""License# <br /> Address y L t '� usiness Phone` <br /> Via: :� - '..~t <br /> Contractor's Name C:I - , _ Emergency Phone- <br /> Contractor's <br /> hone Contractor's Address No A-+ 1 <br /> Is Certificate of Workman's Compensation lQurancDeE��EN i]With SJRL ONDITION❑ESTRUCT101V <br /> i TYPE OF WORK (CHECK): NEW WELL n+ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ - PUMP„INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑-. Sewer Lines Pit Privy ', <br /> { DISTANCE TO 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 /> . ❑ Dia. of Well Excavation <br /> x <br /> 13INDUSTRIAL, CABLE TOOL❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PRIVATE Gaug <br /> [Ie of Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> '❑ GRAVEL PACK Depth of Grout Seal: , <br /> ❑ IRRIGATION I❑ ARY Type of Grout <br /> 1:1 CATHODIC <br /> CATHODIC PROTECTION l❑ ROT OTHER . Other Information <br /> I ❑ DISPOSAL • �` r_ Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractors 1_01 " H.P. <br /> PUMP INSTALLATION: . _., <br /> Type of PUMP` <br /> k❑ State Work-bone <br /> PUMP REPLACEMENT:- <br /> PUMP REPAIR: =---- <br /> 13state Work Done Approximate Depth <br /> �..*�" <br /> DESTRUCTION OF WELL: ! Well Diameter°` n <br /> Describe Material and.Procedure <br /> 1 <br /> I Hereby certify that l 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 /> I aws of.California."- <br /> Home owner or licensed agent's signature cel titles the fallowing:"I certify-t-6ject to workman's hat 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 g:1I certify that n the performance of hempensation lwork for which this <br /> Contractor's hiring h ll employ <br /> personng s subject onature rtifies the workman'sI compensation laws of California." <br /> permit is issued, I shall employ p <br /> I w all fora Go�Inspecfion.pvior to grouting and a final inspection.. <br /> Date: � <br /> Title: <br /> Signed X (Draw-Plot on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I Date <br /> } <br /> Application Accepte y <br /> _T <br /> Additional Comme ts: r ase Ill Final'Inspection <br /> P ase II Grout InspectiolZ� pate 7-2*76 <br /> inspection B <br /> it Date �-� Inspection B <br /> r' --❑ January 1 & ceived By January 31 ❑ July 1 &Received 8y July-31 <br /> REMIT <br /> x Fee Is Due: ❑ ANNUALLY PER UNIT_' C1 PER SITE ❑ EACH REMITTANCE $ AMOUNT DUE CHECKED <br /> r BDATE REMITTED AMOUNT - <br /> - - -- BASE-'" i� - EXPLANATION � DATE DATE <br /> FEE O I <br /> LESS <br /> PRORATION ° <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> Jk <br /> Mailed Delivered: <br /> D to Receipt No. - <br /> PermirNo, Issuance Date <br /> Received by 7601 E.HAZELTON AVE.,P.O.80><2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />