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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �I <br /> FOfa OFFIii E USE: APPLICATION P <br /> ZP-w--&tj (For Non-Traniferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ' Z� "41&f47`=Z&XATER 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 Ordnance No. 1862 and the rules a d regulations of the San Joaquin Local Health District. <br /> Exact Site Address C .., 41. 417 k ity/Town --II <br /> Owner's Name LL , Phone ; �M -W9 -� <br /> Address - =, "' City Z6 <br /> Contractor's Name �.� f License#11 <br /> ® Business Phone <br /> Contractor's Address <br /> E LIZ, r W� Emergency Phone } <br /> �. <br /> I Is Certificate of Workman's Compensation I,,n_surana File-With SJLHD? Yes No P <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN 11 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines / Pit Privy i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ; r ` <br /> 1 <br /> INTENDED USE TYPE OF WELL <br /> ❑ IIy�t7SrTRIAL [3 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION , AV❑ G PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION iid'ROTARY - Type of Grout G S <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL { Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor ` <br /> Type of PumpH.P: <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ state Work Done �� n <br /> DESTRUCTION OF WELL: Well Diameter # - Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and ttiat:tk�e w rlk-wile be done in accordan a with San Joaquin aounty <br /> ^K <br /> ordinances, state laws, and rules and regulations of the San Jodaquip L'ocall F4,alth District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the worktorwhich this Q°ermit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Calif¢rnia." ry <br /> tractor's hiring or sub contracting signature certifles tie oflovuingi l('certifyr4YlA4fi iFie performance of the work for whiii h ibis <br /> er it is issue )shall m loy persons subject to workman's compensation laws of California." i <br /> I it c for.a GIn io Tlg ting and a final inspection. <br /> t <br /> Signed X d Title: Date: <br /> (Draw Plot Plan,bA*,Peverse.5ide).0-r <br /> FOR DE ARTMEN USE ONLY 3 <br /> PHASE i <br /> Application Accepted By Q ---{-- Date " <br /> Additional Comments: <br /> se lout Inspection j I11 Final Inspection f <br /> Inspection By Date Inspection By Datc, ] D <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT - ® PER SITE ❑ EACH - ❑ January 1 &ReceivedRyJanuary 31 ❑ July 1 &Recei ed By Juiy si <br /> I BILLING REMITTANCE $- REMIT <br /> _ p <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE ylMOUNT ` <br /> FEE _ f <br /> `. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ? <br /> OTHER <br /> f <br /> Received by Date '- Receipt No., Permit No-- Is uan a Dalb Mailed _ .Delivered{' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2609 STOCKTON:CA 9524i- <br />