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.-.rr..�_..,............... . .......ea..- ...... ..wAPPLICA71C}Nr,a.rsw - <br /> FOR OFFICE USE: <br /> C%r Non-Transr.; <br /> iel'abie Revo`eabte;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTKPERMIT <br /> (COMPLETE IN TRIPLICATE} WADER-QUALITY <br /> " .. <br /> ist ' forapermitloconstructand/orInstallthework.hereindescribed.Thisapplicationis <br /> Application is hereby made to the San Joaquin Local Health D <br /> made in compliance with San Joaqujn County Ordinance No 1862 and the rules and_ reguiations of the San Joaquin Local,Health District <br /> Exact Site Address'•. City/Town Z- D <br /> Owner's Name r;: .:�,, 5 1 L.tl � . 14 LE: Phbne <br /> Address 70. to. 1 '_ fsfk- City. <br /> Contractor's Name GL K 1,1,x`` L 14 cense# •Business•.Phone '•' 7:G Z.'" Z3�o <br /> Contractor's Address "1.07•' �= C � � `n' '` ''Emerdency Phonel.. r N <br /> Is Certificate of Workman's Compensation InsU a on File <br /> With SJLHD? Yes� No <br /> -. <br /> WELL CHLORINATION 1] WELL ABANDONMENT.❑ OTHER,.[] (TION❑ DESTRUCTION❑ <br />�. - PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> TYPE OF WORK CFIECK}: NEW WELL DEEPEN RECON <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Z8 p Sewer Lines 20Q Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ? 3 <br /> Property Line Private Domestic Weil Public Domestic Well `? <br /> -... <br /> INTENDED USE E OF WELL it <br /> ❑ INDUSTRIAL GABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well:Casing <br /> ❑ D, MESTIC/PUBLIC ❑ DRIVEN + .JGgluge of Casing <br />+ �''1RRIG�TJOfsI...-��.»..�.,,..n4�.-�-._,�, �..:..�_GRA1l.E�.,-P-ACiC-�_�--.... --.. -De�t1�,tOf.GroutSeal.:. •_ i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout a <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> } Type of PumpH.P. <br /> PUMP REPLACEMENT:. ❑ State Work'Done f -� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well:Diamete ;-- ri 4' Approximate.Depth F <br /> Describe tJlateriaFnld� .roCetdure <br /> t 4J pi <br /> l hereby certify that l have prepared this aplication and that the work will be done in accordance with San Joaquin nt <br /> k Y <br /> ol'Eti trances, or licensed aent's:signature.certifies the following:"I certify that in the performance : <br /> Ha' owner' gtate:laws, and rules and re 'ulations of the San Joaquin Local Health District. } <br /> • rmance of the work for which this permit ' <br /> is-issu !d,-I-shall not employ any,person in such manner-as to become'subject1c,workman's;.compensation laws of Calif <br /> mrnl;3.".. ., <br /> Contractor s hiring or sub-contracling signature certifies the following:"I certify.that in the performance of the work for whi m, is <br /> permit I$issued, I shall employ-persons subject to workman's compensation laws of California:" , <br /> Ca a G Anspellon prio to or ting and a-final inspection. t <br /> Z, v g� <br /> Signed- Title:. Date. <br /> (D. w Plot Plan on Reverse Side) ;{ <br /> - FOR DEPARTMEfT 41SE O.NLY <br /> PHASE <br /> Application Accepted By <br /> ;. . a! '-,. ..Date � <br /> .Additional Comments: . 4 <br /> Phase 11 Gro . inspection ''s '° = t i - r it h>#' ll l Finale pection <br /> Inspection By.- Date Inspection B ate <br /> 4 <br /> I FEB Is Due: ❑ AN'NOAL'LY ❑ PER UNIT " [] PErl SITE L1 EACH. © Januaryi &R`ecmved By Jan ary'1T'; I IcJuly 1'&Receied'By July 31 <br /> BILLING REMITTANCE $ <br /> AMOUNT DU 'rHE KED <br /> EMIT <br /> BASE. EXPLANATIati' ti <br /> DATE DATE :REMITTED, MOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> Received by Date Receipt No: - Permit No. issuence ale .Mailed:... - Delivered! <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />