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Applications Will Be Processed When Submitted Properly omp e e l` II ,a <br /> APPLICATION <br /> ATION <br /> poir-OFirICE USE: <br /> (For Non-Transferable, Revocable,Suspend , ) PUMP� <br /> ENVIRONMENTAL-HEALTH PERMIT DEC 24 1981 <br /> r WATER QUALITY .. . . F . ,-.N n�t.l, r, T .Q 1^ ' '' Qe, rl d.This application is <br />` (COMPLETE IN TRIPLicATE) 1s <br /> Application is hereby madeto the San Joaquin Local Health Districkfora permit construct acrd/or I t l�t or�'fie In al fi trt. <br /> wit y�,rdinanc No andthe r5}1,e�and regulations o <br /> made in compliance �m v�r City/Town <br /> Exact Site Address <br /> r— �� Nf7" Phone <br /> Owner's Name x r• = City <br /> Address Z.7— i!J License# S slness Pho { <br /> Contractor's Name GCS- j <br /> `� i�`�; .�� Emergency Phone � <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �,r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECO❑ ITID UMP INSTALLATION ❑ PUMP REPAIR, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER > <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank C <br /> Sewer Lines Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic.Well <br /> 011EOPHYSICAL <br /> ENDED USE Y 4i TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> USTRIAL ❑ DRILLED Dia. of Well Casing <br /> OKD MESTiC/PRIVATE ❑ DRIVEN <br /> Gauge of Casing <br /> MESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> iGATION Type of Grout <br /> THODIC PROTECTION ❑ ROTARY <br /> - ❑ OTHER Other Information <br /> POSAL Surface Seal Installed By: <br /> INSTALLATION: Contractor H.P. <br /> Type of Pump t <br /> ❑ State Work Done y, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> t <br /> t the work will be done in accordance with San Joaquin County <br /> I hereby certify that i have prepared this application and tha <br /> ordinances, state Ilaws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:1 certify that in the performance of thework for which this permit <br /> is issued, I shall of employ any person in such manner as to become subject to workman's compensation laws of California." <br /> g g:, c <br /> Contractor' i ng or sub co ractin ignature certifies the following: l certi ,that in the performance of the work for which this <br /> Pe i d 1 ll empl y perso s subject to workman's campensaf haws of California." � <br /> or r� <br /> sperm irly end a final-inspectio <br /> will c II r a <br /> // II �}�� Date: <br /> Title: <br /> Signed X (.Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Ol Date V a1 <br /> Application Accepted By <br /> Additional Comments: phase III inspection <br /> Phase Ii Grout inspectionD <br /> Inspection By <br /> Date - Inspection By <br /> El <br /> REMIT Jul 1 &Received By July 31 <br /> - <br /> El January 1 8 Received fay Januar y <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE <br /> t - <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE- EXPLANATION DATE DATE REM{ D AMOUNT <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 4 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. <br /> -Permit No. •• 1 suance D to -Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />