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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR"OFFLCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WE=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 1N TRIPLICATE)` - f WATER QUALITY �/tJ` D Z- —f10— Z$ <br /> Application is hereby made to the San Joaquin Local He Ith District fora permit to construct and/or install the work herein described.This application is i <br /> made in compliance ytith San Joaquin Cou ty Ordin nce No. 1862 and he ru es and regulations of the San Joaquin Local Health District. <br /> Exact Site Address / City/Town 1 <br /> Za Phone a <br /> Owner's Nari1 City <br /> Address <br /> Contractor's Name .0 nse#.27/fio;ll Business Phone <br /> Contractor's Address ergency Phone <br /> Is Certificate of Wor man's Compensation Insurance n File W' JL D? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELLDEE=PEN ❑ RECONDITION E] DESTRUCTION❑ C> <br /> B �rWEL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ _ <br /> REPLACEMENT❑ - .,. �.. f V <br /> —DISTANCE-TO-NEAREST:. _- _Septic Tank Sewer Lines��f�- Pit Privy <br /> Sewage Disposal Field Yf y��=^-Cesspool/Seepage Pito=- "` y Other <br /> Property Line ��-- _Private LL Domestic-Weil Public Domestic Well <br /> INTENDED USE .f TYPE OF WE <br /> y, Sd <br /> © INQUSTRIAL �CABLtr TOOL �" - Dia=of Well.Excavation <br /> P/ t : <br /> J,01 ,may <br /> DOMESTIC/PRIVATE v ❑ DRILLED Dia, of Wel}Casing�" <br /> 11DOMESTIC/PUBLIC El DRIVEN Gau"ge of Casing <br /> 11IRRIGATION " �_- ❑ GRAVEL PACK -- ©epth of Grout Seal <br /> El CATHODIC PROTECTION ❑ ROTARYType of Grout <br /> 11DISPOSAL 13OTHLR Other InformationQ <br /> ❑ GEOPHYSICAL : :Surface Seal InstalTed By: <br /> PUMP INSTALLATION: Contractor Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Doneit <br /> lPUMP REPAIR: C3State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k *� Describe Material"and-Procedure. - - - '— <br /> I hereby certify 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this p`erm`it <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Catifo(nia." <br /> Contractor's hiring or sub-contracting signature cerlif!as the follow!ng:"I certify that in the performance of the work for which this <br /> permit is issued, I shall emplo persons subject to.workman's compensation laws of California." <br /> I I will 1 for a Grout Ins on p 'or to grouting and a firial,inspec n. <br /> Signed X .r "Title: _ ' Dat <br /> Draw Plot Plan on Revers'e-Side) <br /> :E FOR DEPARTMENT USE-ONL--Y <br /> PHASEI <br /> t Application Accepted By Date" <br /> Additional Comments: <br /> ` Ph a II'Grout Inspect' h "IFinal In ection <br /> Inspection By Date L-3 -6-1 - Inspection By p <br /> IW <br /> _mss• <br /> Fee Is Due: ❑ ANNUALLY ❑"PER UNIT ❑ PER SITE 11EACH ❑ January 1 &Received By January 31 1 &Received By July 31 <br /> -REMIT <br /> Ii BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - - DATE DATE REMITTED AMOUNT <br /> t FEE 0 d <br /> LESS <br /> PRORATION - "- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ! IssuaDate Mailed Delivered <br /> - _ Permit No.by "� - Date . -Receipt No. =" <br /> APPLICANT—RETURN All COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .. ... __ <br />