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�! � .. <br /> perly IvtC •+ - <br />" Applications Will Be Processed When Su ►PPL�Cp►T10N � <br /> FOR OFFICE USS: (For Non-Transierable, Revocable, Sus pendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r �_3_ Zoo —l2— <br /> U.FWATER QUALITY . A_-"Iln described.This lication is <br /> (COMPLETE IN TRIPLICATE)!,2:1 t� <br /> Application is hereby made to the San Joaquin Local Health District for <br /> a dpermit <br /> the rules and construct <br /> egulatioons ofinstal <br /> e San <br /> Joaquin hework.herel Local Health Distnptp ! <br /> N � s✓ <br /> made in compliance San Joaquin County Ordinance N / S r City/Town <br /> Exact Site Address Phone <br /> Owner's NameCity �� <br /> A.J' _ <br /> Address License#96� - Business Phone oQ <br /> Contractor's Name rr emergency Phone <br /> Contractor's Address/ pZ� <br /> Is Certificate of Workman's CompensS ❑ PUMP lIdS7ALLATlOaNtELL1❑uran DEEPENWith SJL <br /> CONDITION STRUCT ON FUMF REPAIR❑ <br /> E TYPE OF WORK (CHECi NEW <br /> WELL CHLORINATION 11WELLABANDONMENT OTHER <br /> REPLACEMENT 13�""` A Sewer Lines _ !p Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank sl Other <br /> Sewage Disposal Field Cesspool/seepage Pit <br /> Property Line MI Private Domestic Well _A4 C=L <br /> Public Domestic Weil <br /> TYPE OF WELL <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing _ <br /> l [3DOMESTIC/PRIVATE 13 DRILLED <br /> 13 DRIVEN Gauge of Casing Q <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> (IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> 11DISPOSAL ❑ OTHER Surface Seal Installed By: If <br /> ❑ GEOPHYSICAL L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a _ <br /> M PUMP REPLACEMENT: ®'State Work pone <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> ! application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this <br /> ordinances, state flaws, 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 thework far sof 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 /> I Contractor's hiring t employ <br /> any person <br /> nature certifies the following:"I certify that in the performance of the work forwhich this <br /> t compensation laws of California." <br /> permit is issued, I shall employ persons subject to workman's comp <br /> irior to routing an <br /> ( ! will call for a Grout Inspec'on p 9 d a final inspection. Date: d <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted By LI <br /> t Additional Comments: Phase III Final spection <br /> Phase 11 Grout Inspection inspection By Date <br /> I Inspection By Date <br /> REMIT <br /> I, Fee IS Due; ❑ ANNUALLY ❑ PER UNIT ❑.PER SITE ❑ EACH C3 January i &Received By Janu ry 31 E] July i &Received CKEDy 31 <br /> BILLING REMITTANCE., $ AMOUNT DUE <br /> L BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. <br /> I sula"ceIII Mailed Delivered <br /> Received by - Date 1601 E:HAZELTONAVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES - _, <br />