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~ }Applications Will Be Processed When Submitted Properly Completed. taeSure ioa+ ++ ++�^rr•• <br /> APPLICATION <br /> FOR OFFICE USE: <br /> _ (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto,the San Joaquin Local Health <br /> ncehNo5t1862 and phe rules and regu ations oflthe San Joaherni Local Head Dist.This rict. Is r <br /> made in compliance with San Joaquin County Ordinance �� , <br /> City/Town <br /> Exact Site Address g Phone / <br /> r <br /> Owner's Namef City <br /> AddressLicense Business Phone t� <f 9l . <br /> Contractor's Name ��}} Emergency Phone ' <br /> Contractor's AddresstY^ -- <br /> is Certificate of Workman's Compensation In on File 5RECONDITION DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ rPit Privy j <br /> Sewer Lines <br /> DISTANCE TO NEAREST: � septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> r' Public Domestic Well <br /> Property Line Private Domestic Well a <br /> TYPE OF WELL �r <br /> INTENDED USE 11 Dia. of Well Excavation { <br /> ❑ INDUSTRIAL CABLE TOOL <br /> Dia. of Well Casing <br /> DOt< <br /> _ E' MESTIC/PRIVATE 13 DRILLED TM 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ®'F'C(STARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information ' <br /> ❑ DISPOSAL Surface Seal Installe By: o� <br /> 11 GEOPHYSICAL <br /> pUMP INSTALLATION: Contractor H P <br /> 1 Type of Pump <br /> 1 ❑ Slate Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth- <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l'have prepared this app <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance compensation the work for whaws of this permit <br /> is issued, I shall not employ ariy person in such manner as to become I certif subject that nrthe performance of the work for which this <br /> Contractor's hiring or sub-contracting <br /> ersonsgsub9ect to workman'sfollowing: <br /> compensation laws of California." - <br /> permit is issued, I shall employ p <br /> I will c 11 for a Grout Inspection prior to gr in and a final inspection. <br /> Title: 1 Date: <br /> Signed X <br /> (Draw plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase III Final Inspection r�� <br /> Ph e�t Inspections z�pY Inspection By��� `l Date d <br /> Inspection By Date <br /> PER t}NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received y July 31 <br /> RE <br /> Fee Is Due: ❑ ANNUALLY ❑ $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE 'EXPLANATION DATE DATE <br /> FEE [} <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER �... <br /> OTHER .. ... <br /> „ . Issuance Date Mailed Delivered <br /> i Permit No. CA 95201 <br /> Date Receipt No. <br /> Received by 1601 E.HA2ELTON AVE.,P.O-Box 2009 STOCKTO � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />