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�.. �. 4�. <br /> Applications Will Be Processed WhenSubmilleG <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable,Revocable, Suspendable) PUMP&WELL ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) the work <br /> Application is hereby made to the San Joaquin Local <br /> Health <br /> No.it1862 and the r ruses and regulations of the San Joaquini Lo eSl Healdth DistaPpllcation is <br /> made In compliance with San JoaquinCounty �� E � i City/Town n <br /> Exact Site Address �S -� <br /> Phone <br /> 13(7 G <br /> Owner's Name City_14 ��-� <br /> Address License# Business Phone _ r <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensatio*Insranee on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELDEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> 4 WELL CHLORINATION <br /> ❑ WELL ABANDONMENT C3 OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ sewer Lines �"� "Pit Privy <br /> t DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit 1— Other <br /> Sewage Disposal Field <br /> a Property Line =r! Private Domestic Well <br /> Public Domestic Well <br /> /r <br /> ' TYPE OF WELL <br /> INTENDED USE pia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> 1:1DOMESTIC/PRIVATE Gauge of Casing <br /> RA <br /> OMES7iC/PUBLIC ❑ RIVEN f <br /> llll❑ IRRIGATION VEL PACK Depth of Grout Seal <br /> Type of Grout <br /> ❑ CATHODIC PROTECTION 9R_ <br /> OTARY Other Information <br /> [3 DISPOSAL THER _ <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> ry Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i. PUMP REPAIR: ❑ State Work Done <br /> well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> rA <br /> v, <br /> I ,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County � <br /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, W <br /> Home owner or licensed agent's signature certifies the following:"I certify that t the performanceof the work for which this permit <br /> is i�Aued, 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I rill ca or a Grout ins ection prior to grouting and a final inspection. <br /> _ Date <br /> Title: <br /> �1 Signed X , ,. — - w {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> FPHASE I �]1j„- Date <br /> Application Accepted By <br /> Additional Comments: Phase III Fin I Inspection <br /> IS�se-ll Gro Inspection a Date <br /> Date dv,/ Inspection By <br /> Inspection By A A <br /> h . Fee i5 DUB: ❑ ANNUALLY ER UNIT ,❑ PER SITE ❑ EACH ❑ January 7 &Received By January 31 ❑ July t &Received EMITBy uVy 31 <br /> BILLING TREMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> } FEE <br /> �2 LESS <br /> PRORATION <br /> PLUS <br /> 'PENALTY <br /> c OTHER <br /> OTHER <br /> _ <br /> PO�t No issuanc Date Mailed Delivered <br /> Receipt No. <br /> Received by Dates+,.. 1501 E.HAZELT <br /> APPLICANT—RETURN ALL COPIES TO: ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - - ' "ENVIRONMENTAL HEALTH PERMITlSERVICES t_ a <br />