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Applications Will Be Processed When Submitted Properly Complete Sure To Sign The ApplicajiT <br /> FOR oFF;�E ll APPLICATION MAY 2 0 1080 <br /> — <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUNS?&1�'V� <br /> — ENVIRONMENTAL HEALTH PERIW fDAQ� 'IN LOCAL f1J'� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT V <br /> Application is hereby made to the San Joaquin Local Heaith District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Saln Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -__ � tl_ Ilande_ CQL1r 4- — City/Yawn _._. 'tockto 1 <br /> _ Phone _. �'3�–Q 578 - <br /> Owner's Name <br /> Address - `d1TP City 7'GhTt, <br /> Contractor's Name _; t - -r—�,_ � License# 2676 '6 031-3210 <br /> - — <br /> �OO� t Business Phone� _— <br /> Contractor's Address 2 CI r Emergency Phone Same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION G PUMP REPA#R❑ C <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank — — Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspooi/Seepage Pit Other_._ _ <br /> Property Line__ Private Domestic Well -- Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1:oorinan r 's er 7yS2ril� -� <br /> Type of Pump - - ;_ ex S1�Tp <br /> PUMP REPLACEMENT: State Work Done replacer? C'.eiPC IVP H.P.'10UMP <br /> W14'Z I1PW one 'r <br /> PUMP REPAIR: El State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter_ _ Approximate Depth <br /> 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. IN <br /> owner or licensed agent's signature certifies thefollowing:°Icertify that inthe performance ofthe workfor which this permit l <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.'' <br /> Contractor's hiring or sub-contracting signature certifies the following:''I certify that in the performance of the work forwhich this <br /> permit is issued, f shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. 1 <br /> Signed X 7. �. <br /> Title: _ _ C` 'tom,-T � Date: <br /> _✓ (Draw Plot Plan on Reverse Side) <br /> R D ARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Date --- <br /> Phase II Grout Inspection � <br /> Inspection By zPhase III Final Inspection <br /> Date <br /> _ _. Inspection By �z. Date l �/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJUIy 1 &Received By July 31 <br /> ASE - EXPLANAT N BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �- - -- - _ AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION — — <br /> PLUS -- -- - — - - <br /> PENALTY II <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE„P.O.Boz 2009 STOCKTON,CA 95201 <br />