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r Applications Will Be Processed When Submitted Properly Completed.Be <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocabie, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> '7�6� �..f - e WATER QUALITY, <br /> (COMPLETE IN TRIPLICATE S- <br /> Application is hereby made to the San Joaquin Local <br /> Health <br /> District <br /> 1r862 andp r rutles on d regulationsofoftthe San Joaquin)LocalcHealth DistrriiipPlication is <br /> made In compliance with San Joaquin Countyr City/Town IPG <br /> Exact Site Address <br /> o r <br /> Y. Phone <br /> Owner's Name r - <br /> Address �77Business Phone e <br /> License#/�3 Zs� F r <br /> Contractor's Name 'Erbergency Phone <br /> Contractor's Address No I <br /> Is Certificate of Workman's Compensation In <br /> on File With JLHD? Yes STRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION J <br /> WELL CHLORINATION 11r. WELL ABANDONMENT 11OTHER ❑ PUMP,INSTALLATION® PUMP REPAIR© pp <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE , TYPE OF WELL <br />' ❑ CABLE TOOL Dia. of Well Excavation <br /> El INDUSTRIAL Dia. of Well Casing <br /> 11DOMESTIC/PRIVATE <br /> 13 DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION Typeof Grout, y <br /> 13 CATHODIC PROTECTION � �,..., 1:1 ROTARY t <br /> Other Information <br /> ❑ DISPOSAL <br /> El OTHER - F <br /> E3 GEOPHYSICAL Surface Seal insta�Ile_i.By: <br /> 09� <br /> PUMP INSTALLATION: Contractor O <br /> H.P. <br /> Type of Pump ^Z,` <br /> PUMP REPLACEMENT: <br /> IJ State Work Done <br /> State Work Done } <br /> PUMPFAMilow. _ Approximate Depth <br /> DESTRUCTION OF WELL: 4. Well Diameter <br /> Describe Material and Procedure i <br /> I hereby certify that I have prepared this application <br /> the San t the nock will be' <br /> d e in t accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulationsnce of the work for 1 <br /> Home ownerlicensed agent's signature <br /> following; <br /> as to becomcertify <br /> subject to workman's ccompensation laws of CaY forn aft <br /> is issued, I shaa ll not employ any pe son in such manner <br /> Contractor's hiring or sub-cont signature certifies the following:"I certify that in the performance of the work forwhich this <br /> ` permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 w' call for a Grout Inspection prior to grouting and a final inspectio . <br /> Title: p Date: Q <br /> Signe ra Plot Plan on Reverse Side) <br /> j OR DEPARTMENT USE ONLY <br /> PHA I Date <br /> Application Accepted By <br /> Additional Comments: Phas III Final Inspection <br /> Phase II Grout Inspection Date <br /> Inspection By. <br /> Date inspection By <br /> PER UNIT ❑- PER EACH 1:3 January 1 &Received By January 31 E3 July'1 &Received By July 31 <br /> R SITE <br /> Fee IS Due: ❑ ANNUALLY ❑ REMIT <br /> BILLING .REMITTANCE � � AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS a <br /> PENALTY <br /> OTHER <br /> OTHER <br /> tssua e Date Mailed Deti�ered. - <br /> Receipt No. ermit No. <br /> w <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE <br />