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Applications Nill Be Processed W�(F <br /> hen•suorri ieartuperr ....••r• <br /> APPLICATION <br /> M-_ I�. PUMP&WELL <br /> n-Transferable,Revocable,Suspendable)" <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' WATER QUALITY the work <br /> (COMPLETE•ITTTRIPLICATE} i <br /> application is <br /> Applic to Ion is hereby made tothQSal <br /> nJoaqunt in LOrdinanceocal Heal-hNosti862 andrict for a phe rules and regulattioermit to ons of thle San Jo quint Local HeathThilstt <br /> ade in compliance witk��a i Joaq,IIIIli Co Y r� City/Town *� <br /> Exact Site Address_ �,5 •�f E�� C � K� 2.— �V� Zr <br /> I � I <br /> Phone <br /> „ <br /> Owner's Name City <br /> Address C License# t �3 Busi ss Phone bZr <br /> Contractor's Name C <br /> \d.1� f �- <br /> Emergency Phone <br /> Contractor's Address �Z.. No <br /> Is Certificate of Workman's Compensation Insura File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑ RECONDITION❑P INSTALLATION O❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER ❑ <br /> REPLACEMENTD I <br /> Sewer Lines Pit Privy a <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other a <br /> Sewage Disposal Field Public Domestic Well s <br /> Pralperty Line Private Domestic Well <br /> TYPE OF WELL q { <br /> INTEND USE 'IM1 Dia-of-Well-Excavation <br /> ❑,.CARL-E-TOOL � <br /> 1. ❑ I TRIAL ,,-- -� �^ Dia. of Well Casing <br /> DOMESTIC/PRIVATE C3 DRILLED r� <br /> I <br /> 13 DOMESTIC/ 1:1 DRIVEN Gauge of Casing r� <br /> PUBLIC I I <br /> Depth of Grout Seal <br /> ❑ PACK ki j <br /> ❑ IRRIGATION IType of Grout <br /> I ❑ CATHODIC PROTECTION ROTARY <br /> ❑ OTHER Other Information t .+ <br /> ElDISPOSAL'• Surface Seal Installed 8y: <br /> a ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: ; ; Contractor <br /> H.P. » (N <br /> Type of Pump <br /> t PUMP REPLACEMENT: i <br /> 11 State Work Done <br /> I ❑ State Work Done <br /> } PUMP REPAIR: S Approximate Depth <br /> DESTRUCTION OF WELL: I Well Diameter ' <br /> a Describe Material and Procedure <br /> t Ilcation and that the work will be done Irk accordance with San Joaquin County <br /> I hereby certify that.i have prepared this app i <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ~- ''f } .Y <br /> 1 Home owner or- <br /> lInot�ee 4,aoenany Ipersonen such manner certifies the las to beco elf subject to workm n's co pensatiionrk f laws of Cao foor which this mlait <br /> -is issued, I shat � Y <br /> a .0jd g g;' y R _ <br /> Contractor's hiring or sum-contractin signature certiiies,}he tollowin 'I certif that in the erformance of the work forwhich this <br /> permit is issued�l'sall employ persons-subjec to workman's 6ompensation laws of California." y <br /> g. <br /> I will call 10 Grou sp tio"rior-to,grouting-and-a.�inal insp tion.' <br /> , W — Date:Z_ � . <br /> I `- <br /> Title: € <br /> Signed X . t <br /> ! Draw-Plot Plan•on Reverse Side) <br /> FOR DEPARTIMENT USE ONLY <br /> r PHASE I ' ' µ'• 1 Date y`� '��✓l <br /> - ;>.�. <br /> Application'Accepted"By"' <br /> Additional Comments: �� phase III Final Inspection s <br /> Phase II Grout inspection ^' !►'��d), pate �� ' 1,pate Inspection By w <br /> Inspect,on By IIL + <br /> !p gJul Received By July.31 y Y <br /> Fee IS Due:'❑ ANNUALLY ❑ ❑ PER SITE •❑.-EACH EI January 1 &Received By January 31 <br /> PER UNIT <br /> ❑ y 1 & REMI�.� I <br /> BILLWG REMITTANCE $ AMOUNT DUE CHFaKED �y <br /> BASE EXPLANATION DATE DATE REMITTED - �,_.•_+� AMTjL1.NT-- <br /> FEE <br /> LESS <br /> PRORATION /z, <br /> PLUS <br /> PENALTY _ u�.�+•^"'S1 T - _ <br /> ` OTHER <br /> OTHER <br /> suance toa Mailed Delivered <br /> R <br /> Permit No. <br /> j�Y .__ . <br /> eceived.by 'IP Date �. ., -Receipt No. _ VE:,1601 E.RAZELTON AP.O.Box 2009 STOCKTON,CA 952D1 <br /> * :APPLICANT-RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />