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bmiitedPropeny .Vv r <br /> g <br /> FFIAPPLICATION <br /> FOR OFFICE U.SE:- 19 �Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ;SUN 19 <br /> ONMENTAL HEALTH PERMIT <br /> SAN JOAQL1�N "� WATER QUALITY <br /> (Cp14APLETE IN TRIPLICATE) �A TH- DtSTR6CT <br /> re ul t' rIs of the San oaquin Loca! Health District. <br /> b madetothe an oaqumLIS-TRIalthDistrictforapermittoconstrucgtand/orinstalltheworkhereindescribed.Thisapplicationls <br /> Application is hereby <br /> made in compliance witty an Joaquin ounty Ordinance IN 1862 an ter ity/Town / �9 <br /> 'i "Lt® <br /> Exact Site Address phone <br /> Owner's Name �l�/Gity r 7 7 <br /> Address r License#� /f BSlness Phone <br /> Contraf;t Is Name ¢ Emergency Phone ��— <br /> ,. C N 0 <br /> Contractor's Address on File ? Yes <br /> Is Certificate of Workman's Compensation InsuranDEEPEN ❑Ith SRECONDI=TION❑ DESTRUCTION❑ PUMP REPAIR❑ <br /> NEW WELL r <br /> TYPE OF WORK (CHECK): ❑ OTHER.❑ pVMP INSTALLAz.1 I _ <br /> WELL CHLORINATION ❑ WELL,ABANDQNMENT <br /> li - � Pit Privy <br /> REPLACEMENT❑ tic TankQ Sewer Lines Other <br /> i DISTANCE TO NEAREST: Sep r Cesspool/Seepage Pit <br /> Sewage Disposal Field <br /> Public Domestic Well <br /> Property LineJ �Private Domestic Well 1 <br /> TYPE OF WELL __ <br /> INTENDED USE _eil Dia..ofWWell Excavation <br /> OL-IcAbLE TOOL <br /> ❑ INDUSTRIAL m <br /> �,--�....�„�.��- pia. of Well Casing <br /> ❑ DRILLED <br /> DOMESTIC/PRIVATE F [3-DRIVENGauge of Casing r <br /> ❑ DOMEST-IC/PUBLIC 13 Gil PACK Depth of Grout Seal <br /> _ Type of Grout <br /> [IN IRRIGATIQt ' ❑•ROTARY. <br /> 4 mac'. <br /> ❑ CATHODIC PROTECTION { ❑,OTHER 4 Other Information 4 <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> et <br /> ❑ GEOPHYSICAL i Con'tractor� <br /> f l ,. H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑l Work Dane <br /> PUMP REPLACEMENT: t •-^^�� G'State Work Done Approximate Depth <br /> PUMP REPAIR: . <br /> I DESTRUCTION OF WELL: <br /> Well Diameter <br /> 'Describe Material and Procedure <br /> be <br /> one in <br /> I hereby certify <br /> that i have prepared this application and that the ock willHeald District- <br /> with San Joaquin County <br /> Icertif thatintheperformanceoftheworktorwhichthispermit <br /> ordinances, state laws, and rules and regulations of the San Joaquin <br /> Home owner or licensed agent's signature certifies the following:" Y to <br /> manner..as to become subjectwing-.1 certifthatlinrthe performs ce of thework forwhich l <br /> aws of California." <br /> is issued, 1 shall not employ any person in such ch this <br /> Ff <br /> Contractor's hiring or sub-conolracersons subuect to�workmanIsifies the l compensation laws of California." <br /> .,...permit is issued, I shall emp Y P <br /> ction prior to-grouting and a sinal inspeciian. <br /> I will C II for a Grout InspeDate: <br /> Title: <br /> k � <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> 6- <br /> FOR EPA MENT USE ONLY <br /> Date <br /> PHASE I <br /> Application Accepted By <br /> f` Additional Comments: Phase HI Fina! Inspection - <br /> Phas 11 Grout Inspection Date <br /> 1 <br /> Date: __k W Inspection By <br /> Inspection By Jul 1 a Received By July 31 <br /> ❑-January.�5'&Received By January 31 ❑ y REMIT <br /> w Fee Is Due:❑ A ILLY "*❑ PER UNIT ❑ <br /> PER-SITE, ❑'EACH ti �y CHECKED <br /> REMITTANCE .- ! AMOUNT DUE AMOUNT <br /> EXPLANATION <br /> BILLING <br /> DATE REMITTED <br /> BASE q�q <br /> I y[ � <br /> I <br /> FEE <br /> �( <br /> r - <br /> LES5 <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> q OTHER <br /> f�17 <br /> Mailed Delivered <br /> i Permik No. <br /> issuance Dake CA 95201 <br /> f Receipt No. <br /> MENTAL HEALTH PERMIT/SER <br /> {[ 1601 E.Hp,ZELTON Al P.O-Box 2009 STOCKyO <br /> Received by Date � , <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONVICES <br />