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It <br /> bure 1001911 1 —1l <br /> Applications Will Be Processed When Submitted Properly Completed.Be <br /> APPLICATION <br /> FOR OFFICE USE (For Non-Transferable, Revocable, Suspendable) pUMp&VIlELL <br /> yY s ENVIRONMENTAL HEALTH PERMIT <br />` WATER QUALITY applicationribeis <br /> erein desc <br /> (COMPLETE IN TRIPLICATE) construct <br /> Application is hereby made the San Joaquin <br /> .OrdinancLocal e No, 186 for <br /> n permit <br /> the rules and regulations oftthe San Joall the work.hg= Local Healdth Distr.This ii <br />` made in compliance with San Joaquin Cou Y4 City/Town ( C <br /> I <br /> Exact Site Address . Q 3 tP r a d <br /> Phone <br /> j Owner's Name City <br /> k AddressLicense# <br /> t� / 3 Business Phone 5 <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation'Insurance on File❑With SRECONDITION 0 STRUCTION❑ <br /> TYPE OF WORK (CHECK): <br /> NEW WELL DEEPEN <br /> WELL CHLORINATION ElWELL ABANDONMENT 11 OTHER 0 PUMP.INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ t 41Sewer Lines Pit Privy <br /> Other <br /> DISTANCE TO NEAREST: Septic Tank '�a Cesspool/Seepage Pit <br /> Sewage Disposal Fief public domestic Well <br /> Domestic Well <br /> Private Domes <br /> Property Line Private p <br /> INTENDED USE TYPE OF WELL 13I <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing a <br /> ❑ DOMESTIC/PRIVATE DRILLED <br /> ,❑..DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC -�' Depth of Grout Seal <br /> ❑ IRRIGATION VrGRAVEL PACK <br /> ok*• <br /> ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION OTHER Other Information <br /> r ❑ DISPOSAL i Surface Seal installed By: W <br /> E ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> 13State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> ' I hereby certity 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 /> rtifies ia." <br /> the following:"I certify that in the performance of thework 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 Ca <br /> Home owner or licensed agent's signature celiforn <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 <br /> �,Or rout Inspecti, pno i groutin�andd a final inspection. , w <br /> Title: 4 v Date: <br /> Signed X (Dralan on Reverse Side) <br /> FOR EPAR MENT USE NL <br /> PHASE 1 (% 7 Date <br /> Application Accepted By <br /> Additional Comments: Phase III Final Inspection <br /> Phase II Gr t Inspection Date <br /> I inspection By <br /> Date Inspection By <br /> PER UNIT. -Wr PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Suly 1 &ReceiveREMIT <br /> d By July 31 <br /> Fee is DUe:.❑ ANN ALLY CJ <br /> f BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> # r r\ <br /> J � Issuance Date• Mailed Delivered <br /> Date Receipt No_ Permit No. Box 2009 STOCKTON,CA 95201 <br /> Received by _',..a+ 1601 E.HAZELTON AVE.,P.O. <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI7ISERYICES'� - <br />