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Applications Will Be Processed When Sub�1mi�tP� Pro er <br /> T FOR OFFICE USE: (� <br /> (For Non-Transferable, cable,�Sluspen�]agl PUMP&WELL <br /> ENVIRONMENTA AL'W5--- AIIIT <br /> - WATER QUALITY IN LOCM off, <br /> {COMPLETE IN TRIPLICATE) �. U <br /> �1 <br /> rk <br /> Application <br /> iitoof the n°o quinlLoeal described. <br /> District. <br /> pplication is L^ <br /> made in compliance with Scan Joaquin C unt�Ordinance No. 1862 and k rulers al City/Town <br /> Exact Site Address_ �al <br /> Phone <br /> Owner's Name City <br /> Address ® _ License ft/�13 7�3 Business Phone_-� <br /> Contractor' ll <br /> s Name r Emergency Phone � = - <br /> Contractor's Address CT ION <br /> No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> DESTRU <br /> TYPE OF WORK (CHECK): NEW WELL <br /> ABANDONMENT ❑EEPEN ❑ OTHERO❑RECNDITI P❑P INSTALLAT ON❑❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL <br /> REPLACEMENT I- Pit Privy ! <br /> DISTANCE TO NEAREST: septic Tank ��, Sewer Lines <br /> essQool/Seep <br /> Cage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> i INTENDED USE l4 TYPE OF WELL. <br /> ❑ CABLE TOOL Dia. of Weil Excavation <br /> ❑ INDUSTRIAL ' pia. of Well Casing <br /> ElDOMESTIC/PRIVATE ❑ DRILLED <br /> - 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC " ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ IRRIGATION t Type of Grout . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ OTHER „' Other Information <br /> 13 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL;, __ r <br /> f PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump„ <br /> 0-ttate Work Done <br /> PUMP REPLACEMENT: : . <br /> I PUMP REPAIR: <br /> 13 State Work Dane Approximate Depth <br /> r DESTRUCTION OF WELL`. R Well Diameter <br /> k Describe Material and Procedure <br /> 77 <br /> --h hereby certityrthat1-have`preparells application and that the work will begone in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> :"1 certify that in the performance of the work for which this permit <br /> Home owner or licensed agent's signature certifies the following <br /> is issued, I shall not employ any person in such manner as to become sub;ect to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perfoforwhich this <br /> rmance of the work <br /> sub'ect to workman's compensation laws of California." <br /> permit is issued, 1 shall employ persons I ; <br /> [ I will c !!r�rout s l on prior It gro ing and a final Inspec ;Date: <br /> Title:. <br /> Signed X _ {Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> ±� <br /> 21 rQ. <br /> ff PHASE I .1 Date <br /> I; � i r <br /> Application Accepted By <br /> Additional Comments: # <br /> 7 P N 'nallnspection <br /> Pbhase UGrout Inspection inspection By Date <br /> Inspection By <br /> Date <br /> I (t Jul 1 &Received By July 31 <br /> Fee is Due: ❑ ANNUALLY ❑'PIER UNIT (�PER S1TE ❑ EACH C1January 1 &Received By January 31 ❑ y REMIT <br /> I I I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE f EXPLANATION DATE DATE REMITTED AMOUNT <br /> I � <br /> FEE 5' t <br /> LESS <br /> r PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER C <br /> " b 1 <br /> Date Receipt No. Permit No. <br /> dssuance Dale Mailed Deiivered �. <br /> Received by 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURtl.ALL COPIES TO:. ENVIRONMENTAL HEALTH-PERMITlSERYICES , <br />