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Applications Will Be Processed When Submitted`'Properly Completea. neOulu _.W.- <br /> APPLICATION <br /> & Su <br /> t <br /> J (For Non-Transferable,Revocable, spendable) j PUMP&WELL <br /> FOR OFFICE USE: <br /> C� 1! ENVIRONMENTAL HEALTH PERMIT d <br /> WATER QUALITY , application is <br /> (COMPLETE IN TRIPLICATE) <br /> ApplicationisherebymadetotheSanJoaquinLocalnancel�ist�$S2or?Phe constructall e wor nJoherei�ocal ealdth,This <br /> made in compliance with San Joaqui County Ordinance �� _• City/Town �. <br /> 6� . <br /> Exact Site Address Phone- <br /> Owner's Name m City ` <br /> Address °T Lic nse# Business Phone <br /> Contractor's Name Emergency Phone t <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File With SRIECO Yes <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ OT OHER �iTIO UMP INSTAL AT ON PUMP REPAIR <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> REPLACEMENT❑ Sewer Lines Pit Privy ; <br /> DISTANCE TO NEAREST: Septic Tank --k Cesspool/Seepage Pit Other <br /> Sewage Disposal Field . • Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL ` <br /> INTENDED USE 11 CABLE TOOL Dia. of Well Excavation r <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ,® DOMESTIC/PRIVATE 11 DRIVEN Gauge of Casing <br /> -0 DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> [1 CATHODIC PROTECTION ❑ OTHER Other Information <br /> 13 DISPOSAL Surface Seal installed By: <br /> [ ❑ GEOPHYSICAL " ,�[ <br /> I� <br /> � ST•D� / <br /> (_ H.P. <br /> PUMP INSTALLATION: Contractor HType of PUMP <br /> 6 <br /> PUMP REPLACEMENT: _ A4 State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> r r� <br /> he certify that (have prepared this application and that the worK will be done in accordance with San Coun y V J <br /> ordinances, state laws, and rules and regulationscertifies lollowin f the San Joaquin certLocal <br /> o that in the performance of the work for which this permit <br /> r. 9:nner as to y <br /> Home owner or licensed agent's signaturesubject to <br /> aw <br /> is issued, i shall not employ any person in sucs of California." <br /> h the fol owing:`'l certify that inrthe performance ce o4 helwork for which this <br /> Contractor's hiring or sub-contracting signature certifies <br /> r y persons subject to workman's compensation laws of California." <br /> permit is issued, I shall emplo <br /> C- <br /> 1 will tali for a Grout.lnsp io prior to routing and a sinal inspection. f1 I` C� <br /> • � /- Date: <br /> Signed X <br /> (Draw PI t Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> w. Date <br /> PHASE I <br /> Application Accepted B <br /> Additional Comments: III Inal Inspection � f <br /> Phase 11 Grout Inspectiont Inspection By <br /> Date <br /> Date <br /> Inspection By 4 <br /> j 'Januaryy 1 &Rece <br /> - l ived By Juiy 31 <br /> ❑ EACH ❑ January 1 &R ived By t. ❑ JuMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER-UNIT ❑ PER SITE $ 'AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED 'k AMOUNT <br /> BASE <br /> EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> r. 72-- <br /> � <br /> Iss ante Date MaiSed Delivered' <br /> � Receipt No'. ,__ _Permit o. CA 95201 <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMk77SEAYICES <br />