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Applications Will Be Processed When Submitted Properly Gomplecea.ov <br /> APPLICATION <br /> FOR OFFICE US Y/T6 (For Non-Transferable,Revocable, Suspendabie) pUMp &WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is ; <br /> i <br /> (COMPLETE IN TRIPLICATE) <br /> 62 and the rule and regulations of the San Joaquin Local Health District. <br /> Application <br /> herein described.Thls <br /> made m compliance with San Joaquin County Ordinance No. r C}tylTown <br /> � ' � � 9' <br /> 0011 <br /> Exact Site Address phone <br /> Owner's Name 7A City <br /> Address License Business Phonlip e <br /> k Contractor's Name Emergency Phone <br /> Contractor's Address { IO --� <br /> is Certificate of Workman's Compensation insurance on EN With SJLHD? Yes ❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION <br /> WELL CHLOR <br /> INA710N ❑ WELL ABANDONMENT ❑ OTHER ❑ 'PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I REPLACEMENT❑ � Pit Privy <br /> Septic Tank Sewer Lines Other <br /> i DISTANCE TO NEAREST: p Cesspool/seepage Pit <br /> Sewage Disposeaagll Field Public Domestic Well <br /> Property Lined Private Domestic Well P/ <br /> r TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation r/ <br /> ❑ <br /> 11 CABLE TOOL <br /> ❑ DRILLED Dia. of Wei Casing it <br /> 9J"60MESTIC/PRIVATE ❑ DRIVEN Depth <br /> of Casing <br /> ❑ DOM 13 <br /> 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION NARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL <br /> EI OTHER <br /> Surface Seal installed By'. <br /> f ❑ GEOPHYSICAL. Contractor H.P. <br /> PUMP INSTALLATION: <br /> Type of Pump <br /> ❑ State Work Done <br /> ' PUMA REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> i Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I - <br /> I hereby cern#y 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 Local 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 /> to <br /> is issued, l shall not employ any person In such manner as to became owing:"I certify that�onrkman the performance of thecompensation <br /> Contractor's <br /> forwhich this <br /> s the <br /> Contractor's hiring h ll employ <br /> ting sub ect tonature workman'skman's compensation laws of California." <br /> permit is issued, I shall employ persons <br /> I will c I for a Grout inspection prior to groui'ng and a final inspection. Date: <br /> /7 Title: <br /> E Signed X (Dr w Plot Plan on Reverse Side) <br /> FOR DEPARTME USE ONLY <br /> 1 Q Date ' ra <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Phase III Final In ection _ yr L/ <br /> I s I Grout pection Date <br /> p� ��vv <br /> ate D Inspection By. <br /> inspection 8 �~ <br /> +� [3 January i &Rece January 31 ❑ July i &Received By July 31 <br /> Cy R S4TE REMIT <br /> [3Fee is Due: ANNUALLY ❑ PER IT ❑ EACH <br /> PER BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> g � <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 4"? 'a <br /> I <br /> led Delivered <br /> Receipt No. Permit No. <br /> I seance ate Ma <br /> Received 6y Date 1501 E.HAZELTON AVE.,AYE.,P.O.60■2009 STOGKTON,CA 95201 <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />