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n 'by d. d ser c .....- <br /> Fensile Processed fi Submitted Property Completed,e e <br /> FOR OFFICE USE: �y APPLICATION <br /> 694or Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 4XLRONMENTAL HEALTH PERMIT <br /> �° WATER QUALITY, j j <br /> f [)IS ,� <br /> (COMPLETE IN TRIhereby <br /> m CAT �.qq <br /> Application is hereby made totfi�'�an oaquinLocal Health District for apermit toconstruct and/or install the work herein described.This application ls <br /> I' Ordinance No.1Bl and t e rules and regulations of the San Joaquin Local Health District. <br /> made in complianc+:with San Joaquin County <br /> City/Town _ <br /> Exact Site Address 023. <br /> J3 <br /> !,I + Phone. <br /> Owner's Name IJ City <br /> 81 22, <br /> Address <br /> >� License# <br /> Business Phone <br /> Ir <br /> Contractor's Nam <br /> Emergency Phone <br /> Contractor's AdrP <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ��' No <br /> TYPE OF WORK.(CHECK): NEW WELL 2-1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> F WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2— PUMP REPAIR❑ <br /> REPLACEMENT❑ �' <br /> Q �� <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic lank �.� - Sewer Lines-Cess ool/seepage pit =Other --t <br /> Sewage Disposal Field— p <br /> :, Public Domestic Well <br /> Property Line Private DomestiWel1 <br /> INTENDED USE TYPE OF WELL ; <br /> ❑ <br /> 13 CABLE TOOL � �'� Dia. of Well Excavation- <br /> INDUSTRIAL <br /> �UOMESTIC/PRIVATE 11 DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 1:1DRIVEN Gauge of Casing _ <br /> ❑ <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION x''47 <br /> / f _ �•� +. <br /> ❑ CATHODIC PROTECTION NARY µ � Type of Grout <br /> - <br /> e` ❑'DISPOSAL ❑ OTHER Other information <br /> Surface Seal installed By: <br /> ❑ GEOPHYSICAL i <br /> Contractor '� I e'v`e <br /> PUMP INSTALLATION: - <br /> Type of Pump <br /> PUMP REPLACEMENT: El State Work,Done <br /> PUMP REPAIR: ❑ State Work.-Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: .We11'Diameter^ ^ <br /> { Describe Material and Procedure <br /> I 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 regula'fions of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that 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 subject to workman's compensation laws of California." <br /> e work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of th <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection prior t routing and a final inspection. T <br /> r �- � � <br /> ,�., f -S ' <br /> Signed X � �4-' �, , `� Title: <br /> (Draw Plot Plan on Reverse Side) <br /> c FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments <br /> h 11 Grout Inspection ham III F'nal I�ncspe�ctn 2 <br /> Inspection B Date l Inspection By <br /> Fee IS Dile: [I ANNUALLY PER UNIT 11PER SITE © EACH [],-January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> ON MIT <br /> BILLING �, REMITTANCE AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE ,REMITTED AMOUNT <br /> 0 <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> ` 1 1 S <br /> Received by <br /> Date- Receipt No. Permit No.. Issuance Date Mailed Delivered <br /> w' 09 STOCKTON,CA 95201 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20 M1 <br />