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Applications Will Be Proce1 <br /> ssed When Submitted Properly completed. <br /> FOR OFFICE USE: APPLICATION ,J f <br /> (For Non-Transferable,Revocable,Suspendable) //� J PUMP&WELL <br /> ` V ENVIRONMENTAL HEALTH PERMIT //////w <br /> WATER QUALITY ,. . ,.. <br /> (COMPLETE IN TRIPLICATE) he <br /> Application is hereby made the Joaquin LoOrdinancehNostrict for a 1862 andphe rules and reg ermit to construc fatdirons oftti ie San Jo herein uiL deal Health DistaCplic ion is <br /> made in compliance with San Joaquin County t. �.d4 City/Town <br /> Site Address e 1a" too, <br /> Exact - ' <br /> Phones <br /> Owner'S'Name - City `�—^ <br /> Address <br /> +�>- , ., Licenses#;'"/4"Usn <br /> usiness,Phone. s <br /> Contractor's NameP <br /> r, O-� Emergency o e <br /> Contractor's Address No <br /> to of Workman's Compensation Insurance on File With LHD? Yes p <br /> Is Certiflca ❑ _ -DESTRUCTION❑= — �� <br /> TYPE OF WORK {CHECK):"''- NEW WELL❑ "r DEEPEN ❑ - "'RECONDITION V <br /> WELL CHLORINATION ❑ ..WELL ABANDONMENT ❑ OTHER 13 PUMP .INSTALLATION. . PUMP REPAIR❑ <br /> u <br /> i REPLACEMENT❑: - <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST. Septic Tank' Cesspool/Seepage Pit Other <br /> l' <br /> Sewage Disposal Field public Domestic Well <br /> ' Property Line Private Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> x © CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> ' ❑ DOMESTIC/PRIVATE 13 DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC Depth of Grout Seal - <br /> I ❑ IRRIGATION . ❑ GRAVEL PACK <br /> 1 ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ether Information <br /> ❑ DISPOSAL r ❑xOTHER <br /> . . Surface Seal Installed8y:' <br /> 11.GEOPHYSICAL <br /> I � Contractor <br /> PUMP INSTALLATION: 15116X <br /> - H,P. <br /> > Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ) " e•4JR State Work Done <br /> DESTRUCTION OF WELL: f } <br /> Well DiameterTr' YAp roximate Depth <br /> # Describe Material and Procedure <br /> FI`hereby certify that"I.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 <br /> in performance of thwork for wtl <br /> Home owner or licensed agent's signature certifies the following:"I certify that e of California." <br /> 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 orsub-contracting signature certifies the following:"1 certify that in the performance of the work forwhichthis <br /> j of California." <br /> permit is issued, I shall employ persons subject to workman's compensation laws <br /> I ill call.fo a Grout In a to p 'r gro b4andI.Ir ai inspection. �� V912-- <br /> r <br /> ~ Date:Signed Xrrr(Draw on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> „ Z <br /> PkiASE l � Date � I <br /> Application Accepted ByF 111 <br /> � p p - <br /> Additional Comments: . . hose 111 Final Inspection <br /> s ase Il Grout t spectlon 7 Date <br /> Inspection By' <br /> Date -Inspection By <br /> Fee f6 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EIEACH' - ❑ January 1 &Received By January 31 ❑ July 1,&Receive <br /> Rd 6ylTuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE i^^ EXPLANATION DATE DATE 'REMITTED AMOUNT - <br /> t1 4'. - <br /> FEE ✓-✓ s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - - <br /> OTHER <br /> OTHER. /.,,q51 <br /> } 'issuance date ,. Mailed Delivered. 1 <br /> Receipt-No. <br /> Date - - - .Permit No. L CA 95201 <br /> Received by _ -�- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,. <br /> APPLICANT--RETURN-ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />