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! Applications lS <br /> (Will Be Processed When Submitted Properly Completed. B Su fb1n{The G4 tt� <br /> t� pcarnn. <br /> FOI OFFICE USE: h APPLICATION �i-' ` <br /> (For Non-Transferable, Revocable,'Suspenda_fe�j U p&WE UUU <br /> ENVIRONMENTAL HEALTH PERMIT MIA <br /> (COMPLETE 1N TRIPLICATE) WATER QUALITY SAN,JOAQU LO A <br /> Application is hereby made to the San JoaquinLocafWealthDistrictforapermittoconstructand/orinstalo11e��hisapplicationis I <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Loca a it District. <br /> Exact (SIIite Address �3 ��( City/Town <br /> Ownerls Name .......— Phone <br /> Address 9 id te.r City <br /> Contractor's Name .�c1f� /'-� �:�" License#li X32-3 Business Phone <br /> Contra <br /> I. <br /> /00 /9,� /9a7 Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No t <br /> TYPE pOF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ —DESTRUCTION❑ <br /> WELL (CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Er PUMP REPAIR 13 -D <br /> REPL CEMENT❑ <br /> iF N r �' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well <br /> IN' ENDED USE TYPE OF WELL t <br /> - ❑_INDpUSTRIAL ❑ CABLE TOOL' `' `:` Dia. of'Well Excavation - <br /> �� DOIiVIESTIC/PRIVATE ;F ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION �� ❑ GRAVEL PACK' Depth of Grout Seal y <br /> ❑ CA�'HODIC PROTECTION ❑ ROTARY Y Type of Grout I <br /> ❑ DISPOSAL �� ❑ OTHER Other Information <br /> ❑ GE11 PHYSICAL I w Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Oa <br /> �I Type of Pump 'H.P. <br /> PUMP REPLACEMENT: l ❑ tate Work Done <br /> PUMP'IREPA#R: �; u State Work Done Llz t'az- .f�/� r �-���--0t� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth U <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 'f <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit <br /> I 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. .; q <br /> II <br /> Signed X R Title: .. _.s8k���y.�,✓ Date: _�Qz <br /> (Draw Plot Plan on R e se Side) <br /> III <br /> .r <br /> �I FOR DEPARTMENT USE ONLY f <br /> ill n _ <br /> PHASE <br /> I <br /> IlApplication Accepted BY - , ` ria Date <br /> Additional Comments: r� <br /> Pha f rout Inspection pha a III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Pee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE '" EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT I <br /> 11, 41 <br /> h T 7 Vim! L ' <br /> LI <br /> PRORATIONPLUS <br /> I� <br /> FJ=NALTY !! <br /> OTHER l./ NYt l�rlYr{�/ I <br /> 14 <br /> (OTHER i <br /> Received by Date !� Receipt No, Permit No Issuanc Date Mailed Delivered <br /> i'APPLICANT—RETURN ALL COPIESiTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Y1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 , <br />