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Applicatio s Will Be Processed When SubmittedProperly%oomplemeu. I <br /> APPLICATION <br /> i'oR•oFFICE USE: <br /> i' (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL.HEALTH PERMIT <br /> ATER QUALITY ( 9 0 Orb <br /> (COMPLETE IN TRIPLICATE ' �cc! <br /> Application is hereby made totheSanJoaquinLodalHealthDis��ictorapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationls <br /> made in compliance with 5 n Joaquin County Ordinance No.11862 and the r I s�' re ju ns of.the San Joaquin Local Health District. <br />' �� �a� �,� '•lam � a Ity/Town <br /> Exact Site Address As+� ' <br /> Phone <br /> i., Owner's Name City <br /> Address I �' <br /> Contractor' &9_4Daillins Name • Lcense# 373- Business Phone <br /> �R Emergency Phone <br /> Contractor's Address No <br /> i Is Certificate of Workman's Compensation Insurance on File©i SJLHD? I Yes El DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ' <br /> ENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP R <br /> WELL CHLORINATION ❑ WELL ABANDONMEPAIR r <br /> i <br /> REPLACEMENT❑ Pit Privy <br /> t Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field - <br /> i Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE P TYPE OF WELL <br /> 11 INDUSTRIAL <br /> [1,CABLE TOOL Dia. of Well Excavation' w <br /> F E-] DOMESTIC/PRIVATE »❑ DRILLED ' <br /> "� Dia. of Well Casing. <br /> C3 DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ® IRRIGATION- `+ •F11 GRAVEL PACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION x„ '"�`❑ ROTARY Type of Grout <br /> El DISPOSAL 13 OTHER <br /> Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> i� H.P. <br /> Type of Pump 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done <br /> Well diameter <br /> DESTRUCTION OF WELL: Approximate Depth <br /> • :� describe Material and Procedure _ <br /> I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tions of the San Joaquin Local Health District. <br /> ordinances, state laws, and ruses and regula <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 /> C Contractor's hiring or sub-contracting 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 will call for a Grout inspectio or out' and al inspection. <br /> rile: Date: /d 117— <br /> Signed <br /> X / (Draw Plot an on Reverse Side) <br /> I <br /> FOR DEPARTM T USE ONLY I, <br /> k <br /> Date <br /> PHASE I D 3 <br /> Application Accepted By Q <br /> Additional Comments: as al Inspection <br /> Phase 11 Grout spection Date <br /> ( Inspection By <br /> Date -- Inspection By - <br /> { Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT El PER SITE ❑ EACH - ❑ January 1 8�Received By January 31 ❑ July 1 &ReceivedJuly <br /> REMIT <br /> ION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE (REMITTED AMOUNT <br /> I ! <br /> FEE <br /> LESS P 9 <br /> i PRORATION r <br /> r PLUS ` <br /> PENALTY ' ` <br /> OTHER <br /> y OTHER <br /> .i Iti <br /> ..Permit No <br /> ssuance Aa a ailed Delivered <br /> Receipt No. <br /> RDate eceived by - 160t E.-HAZELTON AVE.,P.O.Bax 2009 STOCKTON,GA 95201 <br /> ,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES S _ - <br />