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Applications Will Be ProcessedWhenSubmA?atlFr9perly Gompletea. tse sure roalgn >Ine.+PPI>cauvn. <br /> FOR OFFICE USE: APMICXTION <br /> (For Non-Transferable, Revocable,Suspendable) , <br /> PUMP&WELL <br /> ENVIRONMENTAL HE <br /> A r '5`6 , 'L� ..' ` <br /> . ALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) X e"?, SKATER QUALITY 04`7-t V-1,9 <br /> Application is hereby made to the anoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance wi San Jo gain County Ordin ce No. 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4 City/Town 42 <br /> Owner's Name 13nenzSa1yhyr, Zee4 Phone /y + <br /> Address City_ , a )— _ <br /> Contractor's Name r License#aq yy Business Phone_3 7 <br /> Contractor's Address Emergency Phone 3 & 9—2 7 7� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Q- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C PUMP REPAIR❑ A <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank no^e Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 6 0 h G Other <br /> Property f <br /> p y Line�j+�_..._ Private Domestic Well� Public Domestic Well ' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL IXCABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing pWc <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal II <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _ t <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. t <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 rA <br /> Describe Material and Procedure tvl <br /> L <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. <br /> Home owner or licensed agent's signature certifies the f011awing:"I certify that in the performance of the work for which this permit <br /> 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 following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> pl 1 will call for a Grout Inspection prior to grouting and a final inspection. j f <br /> SignedIX Title: C�-4 e 4Ar Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTM T USE ONLY <br /> PHASE I ��;6 <br /> Application Accepted By Date �� <br /> Additional Comments: <br /> Ph Grout n ection / RPh a it Final spection�, <br /> Inspection By at Inspection Bye. ==r Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> BILLING+ REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 'OTHER <br /> Received by Date Receipt No. Permit No. Is'uance Oale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />