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—App y � � U �1 <br /> I n I!'iB r e d 1 'he mitted Properly Completed.Be Sure oSign <br /> LI PPL{ <br /> CATION <br /> F()R OFf1�E USE: _ - <br /> (gfoor�No sterable,Revocable;Suspendable) PUMP&WELL <br /> SEP 8 `ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRlPLICATE)GAN JOAU1 L®�� <br /> Application is hereby madeto thenQa � � Istrictfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ountyxOr finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. f <br /> City/Town <br /> Exact Site Address "2 313 <br /> k Phone' 9 <br /> Owner's Name ", Cityx--�r9, r <br /> AddressLicense#` - <br /> 7� <br /> �� .� Busines's Phone.. <br /> Contractor's Namem } <br /> Emergency Phone <br /> Contractor's Address J No <br /> Is Certificate of Workman's Compensate n Insurance on File With SJLHD? Yes _ b6 <br /> TYPE OF WORK (CHECK):WELL ABANDONMENT ❑❑ OTHER 11 ITIO UMP INS13- TALLATION❑❑ PUMP REPAIR,❑ <br /> WELL CHLORINAT <br /> REPLACEMENT Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/seepage Pit Other <br /> Property.Line Private Domestic Well Public [}omestic.Well <br /> INTENDED USE TYPE OF WELL . <br /> ❑ INDUSTRIAL ❑ CABLE TOOL " Dia. of Well Excavation. <br /> 0 pal�`ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> [Er 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 /> ❑ Surface Seal Installed By: <br /> GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Typ of Pump <br /> PUMP REPLACEMENT: LJ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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:', <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <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 /> oy persons subject to workman's compensation laws of California." <br /> permit is issued, I shall empl <br /> I will tali for a Grout Inspection,priorto grouting and a final inspection. <br /> Title: Date: <br /> Signed X <br /> y <br /> (Draw Piot Plan on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> i <br /> Application Accepted By <br /> Additional Comments: hase I11 Final Inspection /d �y <br /> Phase Grout Inspection Date Y� <br /> i Inspection By Date Inspection By <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.t &R ceived By January 31 ❑ July 1 &Received By July 31 <br /> _ RET <br /> MI <br /> BILLING REMITTANCE . $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> tyq�G 6 <br /> FEE {�./ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> -- - P <br /> ssua c ate Mailed Delivered <br /> -'- Receivetl by Date Receipt Noermit No, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES „�.f <br />