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... <br /> ,Applications Will Be Processed When Submitted roper <br /> APPLICATION <br /> F,�.OFFICE USE ;� J� <br /> r !(For Nan-Transferable, Revocable,Suspendable) PUMP& LL. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F - WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Dist ict fora peNo. 1862 and the rules anregulations <br /> to construct and/or install the work_herein described.This application is <br /> Applica <br /> made complianceishereb with San Joaquin County Ordinance d of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name O <br /> City <br /> Address ' iessPhone_ <br /> n ?—��9 <br /> Contractor's Name a Oi�ense#_ 6r� . Bus _ ` <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A <br /> 7YPE.OF WORK (CHEM WELEW L,ABANDONMENT 50 DEEPEN <br /> ELL OTHER RECONDITION <br /> ❑ ITIO U❑MP INSTALLATION ❑ PUMP REPAIR❑ ` <br /> F WELL CHLORINATION 11 <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines .. T <br /> Sewage Disposal Field - -- <br /> h- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �y - <br /> 11 INDUSTRIAL. 11CABLE TOOL Dia.'of Well Excavation <br /> i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I a <br /> I E] DOMESTIC/PUBLIC 1:1 DRIVEN Gauge of Casing _ — . <br /> f �GRAVEL PACK <br /> ❑ IRRIGATION 9Depth of Grout Seal <br /> ,_,., <br /> ❑ CATHODIC PROTECTION 1F�'�G <br /> ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _— Other Information .ff <br /> 11 GEOPHYSICAL Surface Seal Installed By: _- a <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump " Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> s Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: T <br /> f Describe Materia! and Procedure.. t. <br /> I hereby certify that I have <br /> prepared this application and that the work will be done in accordance with San Joaquin County���^T <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r <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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ( =� <br /> I wi for a Grout Inspection 9Fiipr to grouting and a final inspection. <br /> ,.Date: 9/1 V7_R - �= <br /> Signed X ---� Title: Secretary <br /> j. <br /> (Dr w Plot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY ` <br /> p PHASE I Date C <br /> } Application Accepted lay <br /> Additional Comments: <br /> _Ph I Final knspectlon��/ <br /> Phase II Grout InspectionDate <br /> `nspection By <br /> Date 3 r�11�7G Inspection Sy <br /> v�� z--"« `�LY` ❑ Jul 1 &Received By July 31 <br /> - Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA ❑ January 1 &Received By.Januar y REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I FEE <br /> 1 <br /> LESS <br /> PflORATION\ <br /> k �! <br /> F PLUS UJJi Cr Q <br /> t} <br /> PENALTY <br /> OTHER <br /> " OTHER <br /> t <br /> 'Date - _ Receipt No: ,Permit.No. Issuance Date - Mailed Delivered <br /> � 'k Received by -" 9•.-ti..; 1601 E.HAZELTON AVE.,P.O.Bac 2009 STOCKTON,CA 95201 <br /> . - APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTALTHEALYH.PERMI715ERYICES – y <br />