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IpropComplex" <br />Applications Will Be Prlocessed When Submitted rVf <br />77n <br />For Non-Transferable,Revocable,Suspendabie)PUMP WELL <br />ENVIRONMENTAL <br />HEALTH PERMIT <br />r. WATER QUALITY application is <br />COMPLETE IN TRIPLICATE} <br />LocalHealthDistrictforapermittoconstructand/ <br />7his <br />Application is hereby made to the San Joaquin <br />with San Joaquin County Ordinance No. 1862 and the rules and regulations <br />ity/ <br />TownSan <br />Joagl Local Heaith District. <br />made in compliance w <br />4f V . 1 ? <br />Exact Site Address g^} <br />Phone <br />jam• !/7 <br />1 <br />City 7 327Owner's Name 1 T <br />r <br />Address License# -2 Business Phone <br />Contractor's Name Emergency Phone <br />5T. No JC <br />Contractor's Address <br />DESTRUCTION <br />r <br />Is Certificate of Workman's Compensation InsurancDeE PE IthJSJNC3RECONDITION <br />INSTALLATION <br />PUMP REPAIR <br />TYPE OF WORK (CHECK): NEW WELL <br />WELL <br />CHLORINATION <br />WELL ABANDONMENT <br />OTHER PUMP 1N <br />REPLACEMENT Sewer <br />Privy <br />Sewer Lines Other <br />1 DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br />Sewage Disposal Field Public Domestic Well <br />Property Line Private Domestic Well <br />TYPE OF WELL <br />INTENDED USE <br />CABLE TOOL <br />Dia. of Well Excavation <br />INDUSTRIAL <br />DRILLED <br />Dia. of Well Casing <br />J S <br />DOMESTIC/PRIVATE <br />DRIVENGauge <br />of Casing - <br />r <br />DOMESTIC/PUBLIC <br />GRAVEL PACK Depth of Grout Seal <br />IRRIGATION <br />ROTARY <br />Type of Grout <br />CATHODIC PROTECTION <br />It] OTHER <br />Other Information <br />DISPOSAL Surface Seal Installed By: <br />GEOPHYSICAL <br />Contractor H.P. <br />PUMP INSTALLATION: <br />Type of Pump <br />State Work Done U <br />PUMP REPLACEMENT, <br />State Work Doneapproximate Depth <br />PUMP REPAIR' <br />Well Diameter <br />DESTRUCTION OF WELL:1DescribeMaterialandProcedure <br />lication and that the work will be done in accordance with San Joaquin County <br />I hereby certify that I have prepared this app r <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />the <br />laws of <br />thisper it <br />Home owner or licensed agent's signature certifies the following:`'I certify that in the performance <br />compensation <br />the work for which <br />Cls <br />permit <br />to <br />is issued, I shall not employ any person in such manner as to become <br />I certifsubjecy thatin the performance of the work forwhichthis <br />Contractor's hiring or subjoy <br />personng <br />s subject to <br />certifies <br />workman' <br />sfollowing: <br />compensation laws of California." <br />permit is issued, I shall emp y P <br />I will call to G out Insp kion prior to grouting and a final inspection. <br />Date: <br />Title: <br />Signed X Draw Plot Plan on Reverse Side) <br />FOR DEPARTMENT USE ONLY 7:7Date <br />TM <br />PHASE I <br />Application Accepted By i inspection <br />he <br />Additional Comments: Phase 1 I Final <br />avI <br />1 <br />rout Inspection 1 Date <br />Date <br />Inspection By <br />Inspection By Jut 1 ived By July 31 <br />PER PER SITE' EACH January 1 &Received By January 31 y &ReceREMIT <br />Fee Ifs DUe: [ <br />3UNIT <br />ANNUALLY AMOUNT DUE <br />CHECKEO <br />BILLING <br />REMITTANCE <br />REMITTED <br />DAAMOUNT <br />BASE <br />EXPLANATION TE DATE <br />gam <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />Y. <br />OTHER J <br />vMailed Delivered <br />Permit No.STOCKTON, <br />Issua cc Date <br />CA95ZOI <br />Receipt No, 1 EHA2ELTON Ave.,P.O.BOY 2009 <br />Received by <br />Date <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />APPLICANT—RETURN ALL COPIES TO: <br />160 E.