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{ Applications Wili Be PrAPPLICATIONocessed When Submitted Properly o <br /> FOR OFFICE USE: (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> l <br /> ENVIRONMENTAL.'HEALTH PERMIT <br /> WATER QUALITY. <br /> (COMPLETE IN TRIPLICATE) <br /> construct a.nd/or <br /> all the work <br /> his <br /> Applicat <br /> ion is hereby made to the San Joaquin Local Health DistrictforaQerrrtr to <br /> and regulattiions oftthe San JoaquinlLoca! HealhTDi trriiictlication is <br /> made in compliance with San Joaquin County Ordinance No. 186 d the Jill City/Town <br /> Ga <br /> Exact Site Address t Phone <br /> tJ C0.7, <br /> Owner's Name City <br /> �.� 1 s( <br /> Address Q License# � Business Ph ne h <br /> Contractor's Name Emergency Phone' <br /> Contractor's Address .. No [ <br /> is Certificate of Workman's Compens�aNtE�Linsurance EEPEN ❑on File With SRECONDITION 0 STRUCTNON PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑- OTHER ❑ PUMP IIVSTALLATlO <br /> REPLACEMENT❑ - t Pit Privy <br /> (fQ Sewer Lines Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Y <br /> Sewage Disposal Field Public Domestic Well <br /> t Property Line Private Domestic Well <br /> 1. TYPE OF WELL <br /> INTENDED USE Dia.of Well Excavation 1? <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> x 13 DRILLED Dia. of Well Casing ` <br /> ,�pOMESTIC/PRIVATE it 11 DRIVEN Gauge of Casing <br /> A Z2 <br /> ❑ DOMESTIC/PUBLIC li' <br /> Depth of Grout Seal <br /> ❑ IRRIGATION pGRAVEL PACK Type of Grout <br /> ❑ CATHODIC PROTECTION i X ROTARY <br /> ❑ OTHER Other Information <br /> ❑ DISPOSAL ii Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor <br /> PUMP INSTALLATION: H.P. <br /> r s h Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done. <br /> PUMP REPAIR: Approximate Depth <br /> • Well Diameter <br /> DESTRUCTION OF WELL: Is <br /> Describe Material and Procedure <br /> !l, <br /> I hereby certify that 1'have prepared d this <br /> sof the San Joaqu n Lo all Health District accordance with San Joaquin County <br /> ordinances, state laws, and rules _ <br /> Home owner or licensI.ed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 shah not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> erfor <br /> Contractor's hiring or sub-contracting <br /> 51 subuere certifies the <br /> ct to workman'sI compensatiotnflawstof Cali--I in theforniamance of the work for which this <br /> permit is issued, I shall employ per 1 T <br /> I will call f r Grout'I spection prior to grouting and a final inspection. Date: <br /> Title: <br /> Signed X (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> /2 <br /> PHASE I Date' <br /> Application Accepted By, <br /> Additional Comments: P ase III Final Inspection <br /> Ph a II out Inspection Inspection B Date - <br /> inspection By 1- - Date t <br /> -� .❑ PER UNIT PER SITE EACH ❑ January 1 6 Received By January 31 C] July 1 R ReceivedREMIT 31 <br /> Fee IS Due: [3 ANNUALLY: $ - AMOUNT DUE CHECKED <br /> BILLING REMITTANCE AMOUNT <br /> - BASE EXPLANATION DATE DATE REMITTED <br /> i r3 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY: - - <br /> '11 } <br /> OTHER , <br /> 'i <br /> OTHER <br /> 3 <br /> � !� 1ss nce Dae Mailed Delivered <br /> Receipt No. Permit No. <br /> Received by <br /> ii Date 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTONN,CA 95201 <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERVICES �.1 <br />