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It s l e et s Yi��¢n U ittedPrOPen wrgr,v.�... <br /> App i _ PPLICATION <br /> F,QR OFFNCE USE: n-Transterable,Revocable,Suspendable) PUMP&W �L <br /> � AR ��{�NV{RONMENTAL HEALTH PERMIT � <br /> ` ��'_AL WATER QUALITY*q,?l'��c �]ccd C� � = . lis application is <br /> (COMPLETE IN TRIPLICATE) , SAN ��� � Tytrictforapermittoconstructand/or install the work herein descHe ribed.This app <br /> Application is hereby made to the Sal <br /> §Pdmade in compliance w: San Joa in ount Ordina �--No: 186 and t rules an regulationsCity/TownSan Joaquin L <br /> �P' ith Dist' cX4 <br />� Exact Site Address � � v� J� f �"� I� ��, pa , <br /> /� �✓f G )e-,J�1 L Phone <br /> C"ity L-1� 1� <br /> Owner's Nam <br /> -57 Address 2d License# usin ss Phone f <br /> LSO <br /> Contractor's Namej �+ _ Emergency Phone <br /> Contractor's Address Yes NO <br /> Is Certificate of Workman's Compensation Insurance on File With SJRL CONDITION❑ DESTRUCTION❑ —�� <br /> TYPE OF WORK (CHECK}: NEW WELL DEEPEN ER ❑ PUMP IN LLATION❑ PUMP REPAIR❑ <br /> t WELL CHLORINATION ❑ WELL ABANDONME f <br /> 1 REPLACEMENT❑ Se i s P <br /> it DISTANCE TO NEAREST: Septic Tank oo/See ge Pit Other <br /> Sewage Disposal Field op _ m -� T public Domestic Well <br /> Prerty Line J Private Doestic Well 11 <br /> ' TYPE OF WELL <br /> INTENDED USE pia. of Well Excavation <br /> ❑ INDUSTRIAL CABLE TOOL <br /> ,� � ❑ DRILLED }f Dia. of Well Casing <br /> C-DOMESTIC/PRIVATE ', El DRIVEN Gauge of Casing <br /> 11 DOMESTIC/PUBLee, Depth of Grout Seal <br /> C1 IRRIGATION `. `❑ GRAVEL PACK Type of Grout <br /> f ❑ CATHODIC PROTECTION THEE ' <br /> ❑ OTHER Other information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> r ❑ GEOPHYSICAL <br /> + Contractor H.P. <br /> PUMP INSTALLATION: 'VA <br /> k Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: © State Work Done Approximate Depth <br /> f LL: <br /> Well Diameter <br /> DESTRUGTION OF WE <br /> Describe Material and Procedure <br /> ordance with San Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in acc <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 /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f4ngpfyContractors ng or sub-c ratting signature certifies the followawstof CaViin the pornlerfarmance of the work forwhich this <br /> per s ed, 1 shall pnyersonssubject to workman's cowll or ut In a io rior t uting and a final insp <br /> Date: <br /> }Title- <br /> r <br /> Signed X, (Draw Plot Plan Reverse Side} <br /> F DEP RTMEN USE ONLY <br /> Date <br /> PHASE I <br /> r Application Accepted By L <br /> Additional Comments: P III Final nspecte:n _ <br /> € Phase II Grout Inspection Date <br /> 1 � Inspection By <br /> B fate <br /> Inspection <br /> ❑ January 5 &Received By January 31 ❑ July 1 &Received By July 31 <br /> �. -PER SITE ❑ EACH REMIT <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT CHECKED <br /> ' BILLING REMITTANCE � " AMOUNT DUE <br /> BASE <br /> EXPLANATION PATE DATE REMITTED AMOUNT <br /> f� <br /> F <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k ' <br /> OTHER <br /> b �z3 � 5'a <br /> ssuanc Date Mailed P.O.Sox 2009 Delivered <br /> ' Receipt No" Permit Na. STOCKTOF� <br /> Received by Date 1601 E.HAZELTON AVE., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HERLTH PERMITlSERVIGES <br />