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Appli is Wili Be Processed WhenVIPPLICATION <br /> itted Properly o <br /> " <br /> rn <br /> AUG I� n_Transterabie,Revocable,Suspendable) PUMP&WELL <br /> (�o{?o <br /> SArp jr P&NMENTAL HEALTH PERMIT I <br /> . LTI DISTRICT WATER QUALITY -�..IC . •.. , "n '�I <br /> n des <br /> (COMPLETE IN TRIPLICATE) " x <br /> IicationisherebymadetotheSanJoaquinLocalHealthDistrictfa dpne uiesandregulatonsotttheSanJoaquinlLocalHeaicribedthDist.This acpylcationis <br /> A'» C <br /> made in compliance with San Joaquin.County Ordinance No. 1862 City/Town <br /> Exact Site Address phone._ <br /> 01 C;F <br /> Owner's Name City <br /> Address 2 ideinse Business Phone" " s <br /> Contractor's Name <br /> ;r;Emergency Phone <br /> Contractor's Address NO <br />` is Certificate of Workman's Compensation.1 surae LO DEEPEN ❑on File No <br /> SJRL CONbITION STRUCTION❑ -PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW W 11 PUMP INSTALLATION �/ <br /> ❑ OTHER <br /> k WELL CHLORINATION C1 WELL ABANDONMENT I <br /> REPLACEMENT 13A.t Sewer Lines Pit Privy <br /> I Septic Tank " Other <br /> DISTANCE TO NEAREST: Disposal_Field Cesspool/Seepage Pit <br /> Sewage -- ,. <br /> II Public Domestic Well <br /> Property Line Private Domestic Well <br /> I TYPE OF WELL <br /> 4 INTENDED USE _❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia_of Well Casing <br /> Uf DOMESTIC/PRIVATE T❑ DRIVEN Gauge of Casing <br /> i ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK, Depth of Grout Seal <br /> k ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> 11 DISPOSAL Surface Seal Installed By: <br /> I ❑ GEOPHYSICAL i Contractor <br /> PUMP INSTALLATION: H.P <br /> 'I Type of Pump <br /> C3 State Work Done <br /> PUMP REPLACEMENT: � <br /> PUMP REPAIR: ❑ State Work Done <br /> 1 : Approximate Depth <br /> f Well Diameter <br /> DESTRUCTION OF WELL: <br /> t Describe Material and Procedure <br /> Joaquin County <br /> I. T iication and that the work will be done in accordance with San <br /> tµ I.hereby certify that I have prepared this app <br /> ordinances, state laws, and rules and regulations of the San Joaquin <br /> thlat{ealth District. <br /> intheQerformanceoftheworkforwhichthispermit <br /> Home owner or Ilcensed agent's signature certifies the following:" certify <br /> is issued;l shall not employ any person in such manner as to become subject to"workrrsan's compensation laws of California." <br /> s hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forw <br /> Contractor's <br /> this <br /> permit is issued, I shall employ persons subject to workman's compensati°n laws of California." { <br /> I1 <br /> I will call for Grout inspection prior to grouting and a ileal inspection. p �1 Date: <br /> 1 Title: - <br /> _ Signed X+- (Draw plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE1 Date <br /> Application Accepted By <br /> Additional Comments:_ _ __ - -o-- - yse 111 Final Ins lion <br /> Phase II Grout inspection �� ` ante <br /> eF.-Inspection By e <br /> „Inspection By__q <br /> D ate <br /> ' ` Jul 1 &Received 8y July 31 <br /> i- ❑ PER SITE" ❑ EACH'" ❑ January 1 &Received By January 31 ❑ y REMST <br /> [ Fee Is Due: D ANNUALLY ❑-PER UNIT r $ AMOUNT DUE CHECKED <br /> REMITTANCE <br /> t BILLING .i:.- AMOUNT <br /> BASE EXPLANATION' DATE DATE REMITTED, O <br /> FEE <br /> LESS ). ._ <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER ; <br /> Is ante Dat Mailed Delivered <br /> - <br /> Receipt-Na. - • Permit No. STOCKTON,GA 95201 <br /> Received by W. Date -- 1601 E.14AZELTON AYE.,P.O.Box 2009 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERV1GE5 <br />