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bmitted Properly Completed.Be SureTosign Ine <br /> Applications Will Be Processed When Su .+Nr.r•�••� <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WE <br /> LL <br /> ENVIRONMENTAL HEALTH'PERMIT 10 <br /> WATER QUALITY 4 =rr application is <br /> e work- <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local HealhN�+s1B62 and rules and regulattiions oftthe San Joaquin Local�HeathZ herein th,District. <br /> made in compliance with San <br /> Joaquin County OrdinanceCity/Town <br /> Exact Site Address Phone <br /> Owner's Name •+ �' City— <br /> Address . <br /> ity <br /> AddressLicense#f Business Phone'_ <br /> Contractor's Namesf <br /> a _ "� "` Emergency Phones <br /> Contractor's Address No -. <br /> Is Certificate of Workman's Compensation insurance on Fil ❑With SRECONDITION DESTRUCTION❑ <br /> TYPE OF WORT( (CHECK): NEW WELL❑ '^DEEPEN } 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ r 4 Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank ,Cesspool/Seepage-Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> tX INDUSTRIAL ❑ DRILLED Dia. of Well Casing r _1 <br /> ❑ DOMESTIC/PRIVATE El DRIVEN Gauge of'Casing`' <br /> DpMESTIC/PUBLIC - LL ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ <br /> IRRIGATION , ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> I ❑ DISPOSAL Surface Seal Install d By: <br /> I ❑ GEOPHYSICAL f .. <br /> PUMP INSTALLATION: Contractor / 11 P. f ,� <br /> i Type of Pump <br /> i PUMP.REPLACEMENT: C3 State' Work Done <br /> PUMP REPAIR: State Work Done Approximate Depth d <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> I + <br /> I I hereby certify that I have prepared this application <br /> with San Joaquin County <br /> and that the work will be done in accord <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 tollowing:"I certify that in the performance m the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Californiai - <br /> s issued, <br /> IContractor'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 /> i I ill call fora Grout Inspection prio t :gio ting and incl inspection. <br /> pate: <br /> Title: �" <br /> Signed (Draw Plot tan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 r Data , <br /> Application Accepted By <br /> Additional Comments: ` 1hese Ill Final Ins ection <br /> Inspection By <br /> Phase 11 Grout inspection k ,Date <br /> Date <br /> * <br /> Inspection By <br /> a / <br /> i 1 Received By July 31' <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January l &Received ey January 3i ❑ duly � REMIT <br /> REMITTANCE - $ AMOUNT DUE CHECKED <br /> BILLING DATE REMITTED AMOUNT <br /> BASE EXPLANATION DATE <br /> FEE <br /> LESS <br /> PRORATION - <br /> .y <br /> PLUS <br /> PENALTY . •} - <br /> OTHER <br /> OTHER Y <br /> Date Mailed Delivered <br /> Receipt No. Permit No, <br /> N AVE.,P.O.8eK 2Q09 STOCKTON,CA 95201 <br /> Received by Date 1601 E.HAZELTO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />