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Applications Will Be P�cessed When Submitted Properly <br /> APPLICATION <br /> FOR OFFICE USE: PUMP&WELL . <br /> (For Nan-Transferable, Revocable,Suspendable) { <br /> 5 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaqun�,LoO��inancehNostt862 andrict fora rules and regulaermit to construct tions oftthe San Joaquin/Local Heath Dilstrict.application Is <br /> made In compliance with San Joaquin County City/Town Galt <br /> Exact Site Address 100 0 E. L fart Rd-• Phone 36 -169 7 <br /> Owner's Name John Dior Yer City Galt i <br /> Address 10030 E. Liber t ��• l 2 Business Phone <br /> Contractor's Name Thi er' Well DrillingLicense# � ;i <br /> Contractor's Address 100 E. Libe Rd. Emergency Phone No (no emplOY86r} <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Q <br /> TYPE OF WORK (CHECK}: NEW WELL® 15EEPEN ❑ RECONDITION 11 [DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ O <br /> s ! -� <br /> REPLACEMENT 1115© Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank 5C) Sewer Lines /Seepage Pit Other <br /> Sewage Disposal FieldCessp Public Domestic Well <br /> Property Line9�__ Private Domestic Well <br /> INTENDED USE TYPE OF WELL t� 50-500- .101 <br /> ® CABLE TOOL Dia. of Well Excavation 0- <br /> ❑ INDUSTRIAL tt { <br /> 13 DRILLED Dia. of Well Casing ] <br /> ® DOMESTIC/PRIVATE <br /> 11 DRIVEN Gauge of Casing <br /> 11I <br /> i DOMESTIC/PUBLIC S <br /> ❑ GRAVEL � <br /> PACK Depth of Grout Seal 0 � t <br /> E3 IRRIGATION Type of Grout b - <br />` ❑ CATHODIC PROTECTION - ❑ ROTARY - { <br /> C3 OTHER Other Information <br /> El DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMPINSTALLATION:` 1 l ontractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / eh <br /> ❑ State Work Done <br /> PUMP REPAIR: �d ❑ State Work Done 1 <br /> Well Diameter - Approximate Depth <br /> DESTRUCTION OF WELL: - <br /> rDescribe Material and Procedure- <br /> I hereby certify that I have prepared thisapplication <br /> atio the SanttheJoaquin work <br /> willHealtbe d a in t accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations <br /> Home owner or <br /> employ personinsuch mannerfiesthe certi /as to becomtefsubject to workman's nythat in the os compensance of the tion!laws of California."it <br /> is issued, I shallP Y <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the per <br /> of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California-" <br /> I wilAcalo Grout Inspect! prior routing and a final Inspection. <br /> Title: - Date: l <br /> Signed ow <br /> X I raw Plot Plan on Reverse Side)- #.�- •- �-=> <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> } Application Accepted By t' <br /> 1 <br /> Additional Comments: ase 111 F' al inspection <br /> FPha a WGrout In5pection -Date <br /> ate� �- �I Inspection By <br /> inspection By I <br /> PER UNIT ❑ PER SITE ❑ EACH E3 January 1 &Received By January 31 July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED _ AMOUNT <br /> 1 �• 3 <br /> FEE J <br /> LESS - <br /> 'n <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 4 OTHER <br /> Issuance Date Mailed Delivered <br /> ti. Date Receipt No. Permit No, <br /> i Received by - t601 E.HAZELTUN AVE.,P.O.Box 2009 STOCKTON,CA 95204 <br /> t. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV10ES <br />