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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TneAppllaallvn. <br /> APPLICATION I` <br /> FOR OFFICE USE: .., r <br /> (For Non-Transferable, Revocable;Suspenda4le) PUMP&WE=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE),.— V-WATER QUALITY.-, <br /> Application is hereby Health Districtfora perm <br /> niadetp theSan Joaquin Local Heaitto construct and/or install the work fierein described.This application is <br /> )� made in compliance with San Joaquin County Ordinance No. 1862,and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address_ r, {� �+'i �� L � O �rr' City/Town R <br /> Owner's Name <br /> /G G! , ' Phorie7 <br /> [� � �'" - <br /> t Cit <br /> Address 1 ;-l(� Lv'R _rf: y .: <br /> License#>� Business Phone <br /> Contractor's Name �..._s .. . - >_ .. <br /> cy�L t--� r r f tea� ' <br /> 3 5 f, t V Emergency Ohio- a M ` j <br /> Contractor's Address +� <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ ' PUMP INSTALLATION ❑ -PUMP REPAIR❑ <br /> REPLACEMENT❑ rr�� �f j <br /> DISTANCE TO NEAREST: Septic Tank v Sewer Lines ly a Yf: Pit Privy Pte' <br /> F Sewage Disposal Field >i�G Cesspool/Seepage Pit Other_ <br /> ` Property Line 7 Q Private Domestic Well Public Domestic WellCIC <br /> INTENDED USE TYPE OF WELL <br /> s <br /> 13 NDUSTRIAL ( E] CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ' ❑ DRILLED Dia. of Well Casing c' <br /> 1:1DOMESTIC/PUBLIC` 11 DRIVEN Gauge of Casing 76d J <br /> IRRIGATION RAVEL PACK Depth of Grout Seal <br /> 13C1CATHODIC PROTECTION Pb�ROTARY Type of Grout <br /> 11DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -' Surface Seal installed By: Gtr !: <br /> a <br /> .PUMP INSTALLATION:.i r Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done I a <br /> PUMP REPAIR: # ❑ State Work Done <br /> tApproximate Depth ' �- <br /> DESTRUCTION OF WELL: (Well Diameter [ <br /> } t Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be d e 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'i signature certifies the following:"I certify that in the performance of the work for which this permit <br /> not employ any person in such manner as to become subject to workman's compensation laws of California. <br /> is issued, I shall <br /> Contractor's hiring or sub-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." i Y <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> �raw <br /> Title: V C•rr'A-, Date:Signed X Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I s - <br /> t Date <br /> Application Accepted.By' <br /> Additional Comments:..'_ _ - � <br /> Pha I rout Inspection <br /> —T Phase III.Final Inspection <br /> Inspection 8y, ° Date inspection 13y .. Date _ <br /> Fee Is Due: ❑ ANNUALLY t ❑ PER UNIT-1 ❑ PER SITE ❑ EACH ETJanuary 1 &Received By January 31 ❑ Jufy 1 &ReceiveREMITuIy 31 <br /> I _ s _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 'SASE_ EXPLANATION DATE DATE REMITTED. AMOUNT <br /> FEE �• � .. _ <br /> LESS F a <br /> ` PRORATION - �( <br /> PLUS 3 1. ✓ IJ F �� <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> Received by D to - Receipt No. Permit No, -Issuance Date Mailed ` Delivered-, '^ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOM 2009 STOCKTON,CA 95201 <br /> � y <br />