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Applications Will Be Processed When Submitted Properly Complet e ,r o, _ TO <br /> APPLICATION <br /> F0 OFFICE USE: i. <br /> k: (For Nan-Transferable, Revocable,Sus ble)rC� �c� � �n PUMP&WELD. <br /> ENVIRONMENTAL HEALTH PERMIT 11 LL •3 U <br /> (COMPLETE IN TRIPLICATE) �� ---- "QUaITY SAN i0iiQUIN LOCAL <br /> (COM i lLbT" k7h&TRQ3 pp <br /> Applicationishereby made tothe San JoaquiniLocalHealth District for apermit toconstruct and/or r cnbed.lhisa licationlis W� <br /> r <br /> made in compliancewithSan Joaquin County Ordi ce No 1882 and the rules and re ulations of the San Joaquin Local Health District. <br /> Exact Site Address r % City/Town ' <br /> �11,.,-,,i 0?.�f �we t�k E,[' oaf "d p� <br /> Owner's Name ceZAA/W �l Phone <br /> !111 111111 !I in X city d• Bi�1F <br /> Address <br /> Contractor's Name /V License# 3�,L�7.53- Business Phone <br /> Contractor's Address <br /> 1 ij 111 elFte Emergency Phone y� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_A— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank '-Sewer Lines Pit Privy . <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> f <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTiC/PRIVATE ❑ DRILLED Dia" of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 29 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL <br /> 11 OTHER Other Information <br /> ' <br /> 11GEOPHYSICAL f Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: I] State Work Done <br /> I' Approximate Depth - <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <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 /> f Home owner or licensed agent's signature certifies the following:"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 -r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: <br /> Signed X <br /> I (Draw­Plot on Revers Side) <br /> I <br /> FO R F'"s.RTM - <br /> a. ; <br /> f PHASE I <br /> I Date <br /> h Application Accepted By <br /> M Additional Comments: <br /> Pba II Final I pection <br /> Phase II Grout Inspection X11 7,��j <br /> Inspection By - <br /> Date inspection 8y%" Date <br /> I <br /> Fee IS Due; ❑ ANNUALLY PER UNVT ❑-PER SITE ❑ EACH ❑ January 1 8 Received By January 31 July 1 8 ReceiveRd MITu1y 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE r <br /> I LESS <br /> PRORATION <br /> k PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by <br /> _ Date Receipt No. Permit No Issuance Date Mailed T Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., 570CKTON,CA 95201 <br /> P.O.Box 2004 x <br />