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., wppiicatlonsWill Be Processed When Submitted <br /> Properly <br /> FOR ?FFICE USE: u T7-Si Application.APPUCATj <br /> ; <br /> [rIJ— rbb (For Non-Transferable, Revoc Suspendable) <br /> r _ P <br /> ENVIRONMENTAL HEALTH P�RIRfI� �g7� UMP&WELL . <br /> k <br /> (COMPLETE IN TRIPLICATE) is 6D �yvATER QUALITY <br /> I Application is hereby made to the San Joaquin Loc Hera"It`hDistricFtf�oJrapermittoconst# <br /> made in compliance with San Joaquin County Ordinance No. 7862 and the rules and ��`ion �tbe�+ (l?AAtrein described.This application is <br /> I Exact Site Address I� e ' ' f0fieT,,Rl uin Local Health District, <br /> � <br /> Owner's Name City/Town�II <br /> Address Ih Phone <br /> City <br /> Contractor's Name !�I <br /> " <br /> �o S <br /> Contractor's Address I License# �P 37� Business Phone <br /> Emergency Phoney' <br /> Is Certificate of Workman's Compeinsation I urance on File With SJLHD? ✓ <br /> TYPE OF WORK (CHECK); NEW WELL❑ Yes_ No I ) <br /> DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ !t <br /> WELL CHLORINATION ❑ WEELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR LJ <br /> REPLACEMENT❑ !f!f 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesJ a <br /> Pit Privy <br /> Sew 0ge Disposal Field Cesspool/Seepage Pit <br /> Pro ert Line Other <br /> p. Y Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11INDUSTRIAL 1 1 - a.TOOL - - <br /> ❑ DOMESTIC/PRIVATE Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑pOMESTIC/PUBLIC ❑ DRIVEN <br /> Q IRRIGATION Gauge of Casing <br /> ❑ CATHODIC PROTECTION 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ DISPOSAL ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump <br /> PUMP REPLACEMENT; 13State Work Done � H,P. <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter <br /> IEDescribe Materia! and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ! <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v <br /> Home owner or licensed agent's signature certifies the foilowin <br /> is issued, I shall not em Jo an g:"I certify that in the performance of the work for which this permit <br /> ploy y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub. ontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, 1 shall em Ia ! <br /> I�p y persons subject to workman's compensation Laws of California." >i ' <br /> I will call for a Grout Inspection prior to grouting and a final inspection. f <br /> Signed X <br /> t <br /> �� Title: Dale: g�--ar 2 <br /> (Draw Plot Plan on Reverse Side) `I <br /> PHASE FOR EPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase fill rout Inspection <br /> Inspection By1�I Pha Ill Fi I Inspection Date Inspection <br /> I Date_ ; <br /> Fee Is Due: ❑ ANNUALLY 0;PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1 &Received By January 37M <br /> ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> I DATE DATE REMITTED AMOUNT DUE CHECKED a <br /> FEE AMOUNT <br /> LESS <br /> PRORATION !I <br /> PLUS � <br /> PENALTY 'I - <br /> P <br /> OTHER NI <br /> OTHER <br /> J a <br /> z co d 1 <br /> Received by Date Receipt No. Perm it No79 � <br /> APPLICANT—RETURN ALL COPIES Tp�l ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Marled Delivered ' <br /> d 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 ' A- <br />