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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transfe able, Revocable, 5uspendable) <br /> r = PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE r, ,.D ATEA QUALITY (r�`--7 o�o -.rp� <br /> ( 1 ..Z�?2S; _.��4 i <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein describ d.This application is <br /> made in compliance wyth an.Jo quin County Ordinance No. 1862 a &I the rules 4kid regulations of the San Joaquin Local Health District. <br /> Exact Site Address r q r Y' t~z ity/Town Az-1��/7"TO/✓ <br /> Owner's Name i✓� C[SC I iQ Np L Alb Phone YK7 ��S 6 "--- <br /> Address r� e City �r G <br /> Contractor's Name LJ?�W �Qy�� � License# Business Phone <br /> Contractor's Address oZ! Ft/trT/� r�Emergency Phone 15— <br /> Is Certificate of Workman's Compensation Insurance on f=ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ��J} <br /> .WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ lJ F <br /> REPLACEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank # i Sewer Lines rVi I Pit Privy A41 <br /> r <br /> Sewage Disposal Field Cesspo I/Seepage Pit Other <br /> Property Line + Private Domestic Well VAqdi Public domestic Well <br /> INTENDED USE TYPE OF WELL•r <br /> 11 INDUSTRIAL © CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 160 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing +11 <br /> I� <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal /01 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout y� <br /> ❑ DISPOSAL OTHER 2 � �[ Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 + . <br /> i <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. v <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r <br /> is issued, I shall not emplo ny pers ' such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or b contracting signa re certifies the follow' :"I certify that in the performance of Ehe work forwhich this <br /> permit is issued, I s al oy persons subI t to workman's co ensation laws of California." <br /> I will ca�fa u ec p for to grout ng and a final ins n. 01 <br /> J <br /> Signed X Title: ✓ Date: J/,� <br /> (Draw Piot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY 9 <br /> PHASE I 074 iEPs�^� ' --- Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph I Final Inspection �z <br /> Inspection By Date Inspection By Date <br /> !Ilk <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By 31 <br /> BILLING REMI,tTRNCE ^ $. REM <br /> BASE - EXPLANATION •AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r �r <br /> LESS <br /> PRORATION k <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601F,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 k <br />