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- <br /> Applications ps VYilI se'P or ceased When Submitted rope <br /> ,l APPLICATION <br /> FOR OFFICE USE: A �J r:T - f <br /> /� -Transferable,Re <br /> (For Non <br /> vocable, Suspendabie <br /> -Tran ) PUMP&W <br /> ELL <br /> G . r,,,., ., . ..,., <br /> ENVIRONMENTAk HEALTH'PERMIT r <br /> WATER QUALITY,s�, } 30 011 ., � lication is <br /> (COMPLETE IN TRIPLICATE) i! ,. <br /> and their les and regulations of the San Joaquin Local Health District. <br /> Application is Hereby madeto the San Joaquin Local Health DistricStffor a permltto construct andlor install the work herein described.This app f <br /> made incompliance with San Joaquin County Ordnance No. City/Town <br /> Exacl Site Address Phone <br /> a.rrr G <br /> wnerrs Name 4,; r� ' <br /> D/ '�% Busi"riess Phone ; <br /> Address _ - ,,, License#'�:�--�. <br /> I Contractor's Name +J �� <br /> Emergency Phone' <br /> Contractor's Address NO — <br /> I ensation Insurance on File With JLHD? Yes <br /> is Certificate of Workman's Comp Insurance DEEPEN❑ RECONDITION❑ DESTRUCTION© PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-13 OTHER ❑ PUMP i1VS7ALLATIO <br /> REPLACEMENT 11 Sewer Lines Pit Privy p <br /> I �.J <br /> DISTANCE TO NEAREST: Septic Tank _ CeSspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line I Private Domestic Well : <br /> 'TYPE. WELL <br /> INTENDED USE Dia. of Well Excavation <br /> C1 INDUSTRIAL I' <br /> C3 DRILLED <br /> DOMESTIC/PRIVATE Dia. of Well Casing <br /> {I !' { rsing <br /> .i 11 DRIVEN Gauge of Ci <br /> sing <br /> __ _ ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ IRRIGATION Type of Grout <br /> � 4. <br /> 11 CATHODIC PROTECTION ❑ ROTARY, 0 OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑.GEOPHYSICAL �0 <br /> Contractor t 6 H.P. <br /> PUMP INSTALLATION: II <br /> I , I Type ofPump <br /> ! ;� ® State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: v t Approximate Depth C <br /> I <br /> DESTRUCTION OF WELL: Well Diameter. <br /> od_ <br /> Describe'Material and"Prd.ure ; <br /> % I <br /> I hereby certify that have prepared this application and that the work will be dobe in accordance with San Joaquin County <br /> ,1, l <br /> cal Health.District. <br /> ordinances;state laws, and rules and-regulations <br /> eclertif eskhefollowin :1 certof the San Joaquin rf that nthe.performanceoftheworkforwhichthisp:emit <br /> g:` certify <br /> that <br /> owner or licensed agent's sign _ <br /> ch manner as to is-issued, I shall not}employ any person Inaiule certif--les the fol owing:1 cersubjtify that in th pcompensation <br /> erforrmance ofthelwork foCalifornia."wh ch this <br /> Contractor's hiring or sub-contracting sign <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection rl r o ou g d a fl i inspection. <br /> f,k.�` Date: 6 <br /> Signed X 4 <br /> g r �� �� - (Draw Plot Plan on Reverse Side) <br /> !I i FOR DEPARTMENT USE ONLY <br /> PHASE 1 it ! Date <br /> Application Accept: y <br /> Additional Comme ts: IPhas 11 Final Inspection <br /> P I Grout Inspection Date <br /> ' Date inspection By <br /> Inspection By <br /> r Fee IS Due: El ANNUAL 1.Y PER UNIT ❑ PER SITE `❑ EACH, ❑ January 1 &Received By January 31 El July 1 &Received81 <br /> R Mt I <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE — <br /> LESS i9i9 <br /> PRORATION ! 9L <br /> PLUS <br /> PENALTY <br /> OTHER E <br /> OTHER �F w <br /> I Date Issuan Date -Mailed Delivered <br /> - -Receipt No.^'� "^�^"` Permit No. <br /> Received'6y 1661 E.HRZELTON AVE.,P.O.Box 2069 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />