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T � TheApplication. <br /> ' Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District fora permit to construct and/or install the work herein described.This application Is <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin Co ma�y (Ofrdinance No. 1662 and the rules and regulations of the Sang Joaquin Local Healt �t�ick <br /> Exact Site Address 04 <br /> Y %� Nig 7-zae-el Gity/Towna '�� <br /> �r�T •��c� �7� III Phone <br /> Owner's Nam City Gl <br /> Address <br /> -710 License d � 'Business Phon <br /> Contractors Name <br /> � <br /> Contractor's Address <br /> . . �}� /P �mergency Phone No <br /> Q/ <br /> � V� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): ' NEW WELLIf� DEEPEN ❑ RECONDITION❑ -' ❑ <br /> DESTRUCTION <br /> ❑ WELL ABANDONMENT El OTHER ❑ PUMP INSTALLATION 9;-- .PUMP REPAIR❑ <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Priv <br /> DISTANCE TO NEAREST: Septic Tank �rt Sewer Lines �": Pit y <br /> s Cesspool <br /> /Seepage Pit Other <br /> Sewage Disposal Field , <br /> Property Line Private Domestic Well Public Domestic Well <br /> PE <br /> TYOF WELL <br /> INTENDED USE <br /> ❑ INDUSTRIAL ❑ CABLE TOOL - -Dia. of Well Excavation <br /> ❑ OMESTIC/PRIVRTE <br /> 11 DRILLED Dia.-of Well'Casing 13 1 <br /> ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION ❑ GRAVEL PACK ! T / <br /> ❑ CATHODIC PROTECTION CtOTARY Type of Grout <br /> 13 DISPOSAL 1:1OTHER Other information <br /> ❑ GEOPHYSICAL /' Sur ce � 7 <br /> Seal lnsed'By: <br /> PUMP INSTALLATION: Contractor rr`/ � u)(4 <br /> 7"�U Rr 1.1j;ie� H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: LCYState Work.Done t <br /> PUMP REPAIR: ❑ State Work Done _ .. <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br />+ a l 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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> V1 will all for a Grout Inspecti prior t routing and a final inspection. <br /> Title: f Date: <br /> Signed X <br /> I (Draw Plot Plan on Reverse lde) <br /> FOR DEPARTMENT USE ONLY d� <br /> PHASf In�_ (1W, ,N9-0`• Date <br /> Application Accepted By VVJJI -- <br /> Additional Comments: <br /> - h e JI�rout Inspection'/� � _ Ph I inal�nspection <br /> I; �7 � Inspection By� Date . <br /> Inspection By Date <br /> ❑ PER UNIT <br /> EI SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 <br /> Fee Is Due: ❑ ANNUALLY REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. iiP•errmit No. is ante Date a; ,Mated'i, i�' Delivered <br /> Received by 1601 E.HAZELTON AVE.,p.0_aox'2b09 :STOCKTbN,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />