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�.: PP Y P r,.�.. <br /> Applications WI Be Processed When Submitted Pt per o <br /> APPLICATION } <br /> i <br /> FOR dFSICI: USE:," / PUMP&WELL <br /> (For Non-Transferable, Revocable, Suspendable) y <br />'c ENVIRONMENTAL HEALTH PERMIT `o � j <br /> 'PATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Ce rr(�f� uJ • �C L/D.JT7 Si` <br /> Application is hereby made to the San Joaquin Local Health Distract ora permit to construct and/or install thew ork herein described.This application Is <br /> made in compliance with San Joa�qquin County�/Ordinance N . 1862 and.t e rules and r inns of the San J�uicn�Lacal Health District. <br /> Exact Site Address <br /> ibt,/6 Sali�t°s� f 41 � ,i W,lb ity/Town <br /> /_ ,� S� ri—r Phone <br /> rs <br /> Owner's Name -------- !^ G City ' <br /> I Address �Q` Q <br /> License#Jft-7 3-� Business Phone_ <br /> Contractor's Name c <br /> LAP 0, Emergency Phone <br /> Contractor's Address No } <br /> Is Certificate of Workman's Compensation"Insurance on File With SJLHD? Yes__� <br /> TYPE OF WORK (CHECK): WELEW L/ABAELL❑NDONMENT ❑❑ OTH RRECO❑ ITI PUMP IN ST ATIIONO❑❑ PUMP REPAIR® <br /> WELL CHLORINATION <br /> REPLACEMENT❑ --% I ' — Pit Privy <br /> Sewer Lines <br /> j DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> I, ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION <br /> 1 <br /> El PROTECTION El ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> 11 OTHER Other Information <br /> Surface Seal Installed By. <br /> ❑ GEOPHYSICAL - � r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P. # <br /> t PUMP REPLACEMENT: ❑ state Work Done -v-. ho <br /> d 19 State Work Done �G�' art�� � �� <br /> PUMP REPAIR: Approximate Depth 'C <br /> I DESTRUCTION OF WELL: Well Diameter ` <br /> Describe Material and Procedure <br /> � 1 hereby certify that l 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 /> Home the following:"I certify that in the performance of the work for which this permit <br /> Homeissued, 1 shall not employ any person in sto become subject to workman's compensation laws of California." <br /> owner or licensed agent's signature ceuch manner as <br /> is <br /> I following:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the <br /> permit is issued, I shall employ persons subject to-workman's compensation laws of California." <br /> I wil call for a Grout Inspection for o ou I g and final inspection.' <br /> r !A le: Dale: <br /> Signed X (Draw Plot Ian on Reverse Side) <br /> .FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> Application Accepted By Q . Date <br /> Additional Comments: Ph de I incl Inspection <br /> Phase 11 Grout Inspection fir. pate <br /> inspection By <br /> Date Inspection By <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 El 1 8 Received REMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> l <br /> FEE �� <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received Date <br /> Receipt No, Permit No. s u rsce 4 to Mailed Delivered <br /> 2009 STOCK70N,CA 95201 APPLICAA NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTUN AVE.,P.O.Bax. <br />