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s Applications W M Be Processed When Subinlite roperl <br /> = APPLICATION <br /> OR OFFICE USE: (For Non-Transferable, Revocable;Suspendable) PUMP&WELL 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> '—WATER QUALITY -a7. _ <br /> COMPLETE IN TRIPLICATE) ��5S0 Sit to <br /> Lt�Ot� ruct # wry E llcatLon is. <br /> AppiicationisherebymadetotheSanJoaqulnLocalHealhiDDstrict for a 1862a dphe rules and reguiatdions oftthe,S n Joaquin lLocal Health District. <br /> made in compliance with San Joaquin County Ordinance City/Town a <br /> Exact Site Address - <br /> ,.,�, e t Phone tbKrt ' <br /> Owner's Name ,� r ' , ��:.� , „rv,t .r City <br /> Address 'License#_jr — Business-Phone <br /> t Contractor's Name :..,: =�, . 'Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File❑With SRECOND1T10N STRUCTiON❑ } <br /> TYPE OF-WORK (CHECK}: ' ~NEW�WELLgk'�DEEPEN <br /> WELL CHLORINATION 13 WELL ABANDONMENT-13OTHER ElPUMP INSTALLATION.❑, PUMP REPAIR <br /> I <br /> REPLACEMENT❑ In 'xopen AgS�vV �L1eld Pit Privy <br /> _ <br /> DISTANCE TO NEAREST: Septic Tank e ,nes Cesspool/Seepg a e Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> r Property Line Private Domestic Well <br /> TYPE OF WELL " <br /> INTENDED USE X pia. of Well <br /> ❑ INDUSTRIAL Excavation f tI <br /> ABLE TOOL <br /> i ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal ,( 4 <br /> IRRIGATION ❑ ROTARY Type of Grout I (� <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other information 9 C <br /> 11 DISPOSAL Surface Seal Installed By: <br /> []' GEOPHYSICAL <br /> k PUMP INSTALLATION: Contractor z - H.P. <br /> Type of Pump <br /> t ❑ State Work Done <br /> PUMP REPLACEMENT: � ❑ State Work Done _ .,_ - <br /> PUMP REPAIR: _ I _ . Approximate Depth 9 <br /> tWell Diameter ,,,m� , � .0 <br /> DESTRUCTION OF WELL: � - � - <br /> ' Describe Material and Procedure <br /> a re ' <br /> I Hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and rtigulations of the San Joaquin Local Health District. <br /> rk <br /> Ince of thew Homeowner or lice t em agent's <br /> personen such mannerias to become subject`to workmanthat in the as compensation for <br /> of California."Ca1'Ifa permit <br /> ait � 1 <br /> is issued, I shall no employ , <br /> I Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work for which this 1 <br /> permit_is issue , I sh p rs s subj t to workman's compensation laws of California." <br /> I It o n c n p o r t ng and a final inspection. 1 82 <br /> .Title: VP--Clark Date: 6 ®c�o. <br /> Signed X <br /> . (Draw Plat Plan on Reverse Side) <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> LL }PHASE 1 a Date ����-a� <br /> Application Accepted By <br /> Additional Comments:. i Inspectiory <br /> Phase 11 Grout Inspection / Z <br /> Inspection By n <br /> Date Inspection'By Datelo <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT - PER SITE EACH '-❑ January 1 8 Received Ey January 31 ❑ July i &ReceiveR�EMIJuly 31 <br /> EASE. EXPLANATION :BILLING REMITTANCE $ AMOUNT DUE CHECKED '. <br /> DATE DATE REMITTED AMOUNT <br /> FEE, <br /> LESS <br /> PRORATION -+ <br /> PLUS _ s <br /> PENALTY - <br /> OTHER <br /> OTHER . <br /> � - 7 v k <br /> Received by <br /> Date Receipt.No. Permit No. +_ Iss ante a e ,3 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.809 2009 STpCKTON,CA 95201 <br />