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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: AOLICATION ' <br /> (For Non-Transfera}ble, Revocable, Suspendable) a4 <br /> C <br /> r ENVIRONMENTAL HEALTH PERMIT PUMP&WALL , <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or inanfc/e No. 18 2 and the rules and regulations of the San Joa uin Lo7al Health District. <br /> Exact Site Address Lt �++ City/Town ;c. 6n/ <br /> r <br /> Owner's Name Z2Z544..q A,4/ _ Phone 57.2 <br /> Address '� City_Af cod c e <br /> Contractor's Name 11ygrzG !)E/� r2,��+r�. License# s7l Business Phone — 1 !b <br /> Contractor's Address 50/. 5e Au 1&- AU Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTOI <br /> f <br /> DISTANCE TO NEAREST: Septic Tank �6,0 + Sewer Lines .CIS + Pit Privy <br /> Sewage Disposal Field_� Cesspool/Seepage Pit �-� Other <br /> Property Line.//-') Private Domestic Well ;SWP 4 Public Domestic Well <br /> INTENDED USE USE TYPE OF WELL <br /> H i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> u <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / t <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing e-&cg <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout � Z!m Q <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: V r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit a <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I wi all for rooflinsp on prior to grouting and a final inspection. C� <br /> Signed X Title: Dale: �}N <br /> (Draw Plot Plan on Revers"ide) <br /> 71, <br /> PARTME USE ONLY <br /> PHASEIA�Application Accepted ByQ v Date v "'� <br /> Additional Comments: <br /> Phase II Grout Inspection 96aae Ili Final Inspection <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: 11 ANNUALLY <br /> El UNIT ❑ PER SITE El ❑ January 1 4.ceived By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REWTTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -a <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT---RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box,2009 STOCKTON,CA 95201 <br />