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Applications Will Be Processea Ween Suomittea Properly GOmpieted. be sure To Sign The Application. <br /> FOR OFFICE USE: f-; APPLICATION <br /> I or Non-Transferable,Revocable,Suspendabley PUMP&WELL . <br /> ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q . , <br /> Application is Hereby made to the San Joaquin Local Health District fora permit to construct and/or instate the work herein described.This application is <br /> made in compliance wp San Joaquin Co nS Ordinance No.1862 nd the rules ar�d regulate��f_the San Joaquin Local Health District. <br /> Exact Site Address — C" Tow 61 <br /> Owner's Name1�3_. B �3 L { (.Gf�1 Phone <br /> Address city ° <br /> Contractors Name License#I Business#Phone <br /> Contractor's Address *iiergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK):. NEW WELL' . DEEPEN C1RECONDITtON❑' DESTRUCTION'❑' <br /> . . <br /> WELL CHLORINATION ❑. WELL ABANDONMENT 0 . t..OTHER Q PUMP INSTALLATIONPUMP REPAIR❑ 1 <br /> REPLACEMENT 13f f <br /> DISTANCE TO NEAREST: Septic Tank n Sreer Lines Pit Privy <br /> x 1: <br /> Sewage Disposal Field ; Cesspool/Seepage Pit __i Other <br /> Property Line Private Do`mestlaWell Public Domestic Wei( <br /> INTENDED USE TYPE OF WELT_ <br /> INDUSTRIAL ❑ CABLE TOOL. DIa.al IVVeII Excavation „. <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> • r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal F <br /> ❑ CATHODIG PROTECTION �r ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL. Surface Seal installed By: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump MP <br /> IA <br /> PUMP REPLACEMENT: 0 State VVork Done i I' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxi AtO Depth ` <br /> Describe Material and Procedure' <br /> r 1 <br /> I hereby certify'that I'have-prepared-this application and�that the work will be done in with San Joaquin County <br /> ordinances, state laws,and rules and regulations of the $ tszm4bibin Local Health District. <br /> Home owner or licenseli agent's signature certifies the fotlowing:'166rtify that+n the performariceof the Work for which this permit <br /> is issued Lshall Fiteinplo*, nyjpetsontA.such mann[as to iaC ie, t�� pt to workman's compensation laws of California." ,4T, <br /> Z;ontracior's fii�i or sub�eoittradling signature'e¢rli�les the following•'"I eertity-hat In the performance 61 the work for,which this <br /> pe"r"mit'is issued,,i shall errtploy persons subje t to.-"o kmah's corb bns�titin laws of'Califorriis." y <br /> I.wil ca1E for a Grout In ction priori grou. n and a fine Inspection 44 <br /> Signed X f Ti11e: / bate• `��.�—O. <br /> (Draw Plot Plan on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY " <br /> PHASE i <br /> Application Accepted by Date <br /> Additional Comments: <br /> &e, <br /> rout JnspectlonPhase III Final InspectionEnspection.By (late `-! � Inspection By Date ' <br /> AV <br /> Fee Is Due: 13'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JaObary 1 &Recei3ed By Janda '31 ❑ July-1 &Received By July 31 <br /> ��.❑❑ $G tis <br /> REMIT <br /> EXPLANATION AMOUNTDUE CHECKED DBASE BILLING REMITTAIV <br /> DATE DATE 'AITTED <br /> + AMOUNT <br /> FEE `a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> 3 - [l3� ID- 1�_ -�3 <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 />