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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FOR OFFICEVSE: APPLICATION <br /> r (For Non-Transferable, Revocabie,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby made to the San.Joaquin Local Health District forapermittoconstruct ar, r install the work herein described.This application is <br /> made in compliance with San JoCounty Ordinance No. 18fi2 and the;rules and Yegulations of the San Joa uin Local Health Distri t. <br /> Exact Site Address 1819fein <br /> ro k&e City/Town <br /> L Dom.) <br /> Owner's Name Mc gath I Phone <br /> Address :f . t: -�� .- r , ..,.� r� t� City <br /> Contractor's Name Hunger Demol i ti on,#,,,r.- ` License# '` ' Business Phone 474-2077 C <br /> Contractor's Address ' r '' t^ `�=rt,. T " 2Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ CESTRUCTICiN —WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INtb PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> .4 Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> ' NT ENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL �❑ CABLE TOOL Dia. of Well Excavation <br /> r DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 0 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:, <br /> PUMP INSTALLATION: `4 Contractor F <br /> + k Type of Pump H.P" t <br /> PUMP REPLACEMENT: ❑ State Work-Done <br /> PUMP REPAIR: x # ❑ State Work Done ' "'- <br /> r DESTRUCTION OF WELL: ' ! Well Diameter Appro �at5Depth <br /> a ed <br /> Describe Material and Procure <br /> a` �. <br /> x. a . <br /> s` <br /> I hereby certify that I have prepare th s app kation and t the work will be done in accordan ith San Joaquin County <br /> f ordinances,state laws, and rules and regulations of the San JoaquinLocal Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify 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." C ,,, ,, A <br /> Contractor's hiring araub-contracting signature certifies the following:"I certify that in the performance of the work for which this +. <br /> permit is issued, I shall employ persons subject-to workman's compensation laws of California. '.. c. <br /> ) <br /> I it call for Ln ection riot to grouting and a-final inspection. <br /> Signed X: r -r e= "u. Title: Demo. Contractor Date: 9-7T$2 <br /> Draw Plot Plan on Reverse Side} t <br /> FOR DEPARTMENT USE ONLY ) <br /> PHASE I © vP'11oL. <br /> i' Application Accepted ByOLNSLaDate 1 <br /> ' Additional Comments <br /> ha I.Grout Inspection 7 + ` PhaseXI i al Inspection <br /> ` Inspection By Date �� { Inspection By. Date <br /> F <br /> Fee Is Due: ❑ ANNUALLY _ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received$y July 31 <br /> REMIT <br /> _ _ BILLING REMITTANCE $ <br /> BASE , ' EXPLANATION DATE -DATE REMITTED AMOUNT DUECHECKED <br /> I - AMOUNT <br /> _ O <br /> FEE $10.00 destruction . <br /> LESS o- <br /> PRORATION - b <br /> PLUS <br /> PENALTY — <br /> OTHER ` <br /> OTHER <br /> _ <br /> .Received by ., •`Date _,"Receipt No.< - __.,�,,-Permit No-. .,,,�.�,,,._ r- Issuance Date r Mailed ,.Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: E V RONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />