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Applications Will Be Processed When Submitted Properly Completed. -e Sure 7o Sign The Application. <br /> F FUR OFFICE USE: I APPLICATION f <br /> 1 epAt p/a� (For Non-Transferable,Revocable,Suspendable) / .i <br /> f ENVIRONMENTAL HEALTH PERMIT ! PUMP&WELL �' <br /> COMPLETE IN TRIPLICATE), -QQ ep S._ .//����..,,�� �� GG1.o� ,�WWA,TkIl QUALITY (,-7 <br /> Application is hereby made to in an JoaquintiSdfl'('H'ea�nOlstr etfor a"peirfiittondnstruct and/or install the work herein described"This application is <br /> made in compliance `wi San Joaquin County Ordinance No.1862 andand thedtions of the San Joaquin Local Health District. <br /> Exact Site Address_/K Heir �s-� y' �J�h <br /> ice•-,/� City/Town <br /> Owner's Name +r_cT Phone <br /> Address <br /> k Contractor's Name License If 7Y �' City r' <br /> CF3 Business Phone 1i7+7�7t <br /> Contractor's Address Emergency Phone "— <br /> Is Certificate of Workman's Compensation Insurance on F With SJLHD7 Yes, _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPE ❑ RECONDITION❑ DESTRUCTION❑ <br /> 1 WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ PUMP REPAIRIZ <br /> ` - r.. U' <br /> I. DISTANCE TO NEAREST: Septic Tank T_ Sewer Lines .' Pit Privy <br /> Sewage Disposal FieldCesspool/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 i ❑ DRIVEN Gauge of Casing <br /> I�IRRIGATION l ❑ GRAVEL PACK Depth of Grout Seal <br /> :❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface eal Install , <br /> PUMP INSTALLATION: Contractor--- a . <br /> �L � <br /> 'type of Pump_'�'�� H.P, d �` <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> UMP REPAIR: 13 State Work Done Y• l <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure n S <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Hearth District. rIx�L <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thbwork forwhich 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." _y <br /> Contractor's hiring or subcontracting signature certifies the following;"I Certify that in the performance of thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." t <br /> t <br /> I wirl call for a Grout Inapectl pd r tp-Tr–oVAng anqLa final inspection. <br /> ( I , <br /> Signed ?#Mae Date: <br /> (Draw Plot'Plan on Reverse Side) <br /> j FOR-DEPARTMENT USE ONLY <br /> PHASE t - �y�Y'1�Q1 i77 <br /> Application Accepted BY +�-` WJ y Date l.LSd i <br /> Additional Comments: <br /> Phase Grout Inspection Ph se RI Final Inspection <br /> Inspection BY Date. Inspection By�'` Date 2� <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT. SITE ❑ EACH .❑ January 1 8 RacalveG ey January ❑ July Y 8 Reca'netl By July 31 y <br /> a1LUNG REMITTANCE REMIT ! <br /> BASE EXPLANATION 9 AMOUNT DUE CHECKED <br /> DATE GATE REMITTEDI <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 4 <br /> OTHER <br /> OTHER T <br /> fleceivetl DY Dere I Receipt No. Pormit No. Inuante Dae Mallen Delivered <br /> APPL"NIT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES' 14M E HAZELTON AVE..P.O:B.WN STOCKTON,CA 95201 4 <br />