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Applications Will Be Processed When Submitted ProperlyCompletea. itse zoure It;alvii, F <br /> I <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMp&WELL , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE 1N TRIPLICATE) ( plg7 S • �C L' `�� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqukn County Ordi ante No.1862`ndthe rule�an�regulati City/Townons of the S� Joaquin Local alth�istri .lam <br /> Exact Site Address d (5 F ��E N UC— <br /> I LHE-inlC L V Phone <br /> Owner's NameIt! City L <br /> Address - 0- <br /> rl. 1' Business Phone <br /> e 3 License# + <br /> Contractor's Name <br /> Contractor's Address14 iv 74 <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes <br /> No _ <br /> TYPE OF WORK (CHECK): <br /> WELL ANDONMENT �DEEPEN ❑ OTHER O❑RECONDITION❑P IN DESTRUCTION ALLAT ON ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION 4 <br /> REPLACEMENT iv <br /> j Sewer Lines Pit Privy <br /> I DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well <br /> Public Domestic Well T <br /> t TYPE OF WELL 1 <br /> INTENDED USE / <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Casingtion l0 <br /> ( DRILLED Dia. of WellCasing <br /> L ❑ DOMESTIC/PRIVATE <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal p <br /> Type of Grout /V �"�"T �-� r � <br /> ❑ CATHODIC PROTECTION ❑ ROTARY � <br /> r ❑ OTHER Other Information �] <br /> ❑ DISPOSAL I Surface Seal Installed By: -J <br /> N GEOPI 1*6IGA C�Eo i e++ N JC-Ai, <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> r PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i r Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: S <br /> I # Describe Material and Procedure G <br /> } r <br /> f I hereby certify that I have prlepared this application and that the work will be done in accordance with San Joaquin County L <br /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit V <br /> t is issued, I shall not employ-any person in such manner as to become subject to workman's compensation laws of California." <br /> } Contractor's'hiring or sub-contracting signature certifies the to <br /> "I certify that in the performance of the work for which this <br /> permit is issued, I shall e ploy persons subject to workman's compensation laws of California." <br /> 1���`N FE Pl <br /> I wl i ca I for a rout In c prior to routing and a final inspection. 'a? <br /> Title: Date; <br /> d <br /> Signe <br /> I (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> } <br /> PHASE I J Date <br /> Application Accepted By <br /> Additional comments: hose 111 Fin nspection <br /> InspectioDate <br /> Phase 11 Grout Inspection <br /> IT <br /> 1 Inspection By Date f <br /> yk Fee IS Due' ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &ReceiveduIy 31 <br /> REMIT <br /> t - BILLING REMITTANCE $ AMOUNT DUE, CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Ll 3 <br /> FEE <br /> LESS <br /> k PRORATION <br /> f PLUS <br /> PENALTY <br /> k <br /> OTHER <br /> l OTHER <br /> a A r d S Ito <br /> ) Receipt No. Permit No. I uance ate Mailed Delivered <br /> Received by Date ))))1 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES T. ENVIRONMENTAL HEALTH PERMITlSERVICES <br />