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'Applications Will Be Processed When Submitted Properly Completed. taesure iosign ine <br /> FOR OFFICE USE: APPLICATION <br /> n _ a (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY _ <br /> (COMPLETE IN TRIPLICATE)_Q O_ 04�'r.� 14 — rrrr��� S g2"0S o <br /> Application is hereby madeto the San Joaquin Local Health Districtfora perm rules <br /> construct and/or install the QfSerein described.This application is <br /> made in compliance wit San Joaquin County Ordina ce No.1862 and the rules and regulations of the Sa5t�Q 1-4-111 <br /> l Health District. <br /> -( , Q W City/Town <br /> Exact Site Address o <br /> Phone <br /> Owner's Name e <br /> Address 1P,�- ( City <br /> Contractor's Name w o V,t License#.3 t(. Business Phone_ • `~ <br /> Z C3 <br /> O <br /> Emergency Phone —2 at C3 <br /> Contractor's Address <br /> No y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLWD? Yes 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION $ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION JS PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Pit Priv <br /> DISTANCE TO NEAREST: Septic an0947 Sewer Lines r Other <br /> Sewage Disposal Field Cesspool/Seepage Pit s <br /> Public Domestic Well <br /> ' Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL c <br /> 11 INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation r Z <br /> r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing (fi <br /> ❑ DOMESTIC/PUBLIC ❑ Gauge of Casing I <br /> DRIVEN <br /> El IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION `ROTARY Type of Grout <br />' <br /> 1:1 DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Si%al Installed By: <br /> PUMP INSTALLATION: Contractor CaCC C.r" (�' <br /> Type of Pump e N.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL. Well Diameter <br /> Approximate Depth <br /> h Describe Material and Procedure <br /> x <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 Lo cal'Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certity'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 /> ntractor's hirin -c trotting signature certifies the following:P'1 certify that in the performance of the work forwhich this p <br /> pe it is is <br /> , 1 shall em, iy persons subject to workman's compensation laws of California." <br /> I 'I all i rou Inspec o prior to g outs and a final inspection./- <br /> Title: <br /> ns ection. <br /> Title: "'p a Dale: <br /> Signe <br /> Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY I <br /> Date VD -Z-10P <br /> PHASEI [ <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 1 Grout Inspection <br /> ha�111 Final I spection <br /> Inspection By ate <br /> Q—30— inspection By Date 3 <br /> ❑ ❑ PER UNIT ❑ PER SITE El EACH El January 1 &Received By January 31 ❑ July 1 &Received By uly 31 <br /> Fee IS DUB: ANNUALLY EMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> o <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ` Date Receipt No. Permit No. t s4uance Date Mailed Delivered <br /> 9 Received by <br /> 1601 E:HAZELTON AYE.,P.O.6a■2009 STOCKTON,CA 95201 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERYICE5 - <br />