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_.—...� <br /> Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION PUMP&WELL <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable)i; <br /> ENVIRONMENTAL HEALTH PERMIT c�63 lbe_C�o --lf <br /> T R uA iTY application is <br /> "Loaf E.ehD t��++ tmit. ? <br /> (COMPLETE IN TRIPLICATE) Z�?SA <br /> Application is hereby made to the San Joaquin Local HealthlDDst18fi2 a dP he rules and regulations oftkhe San Jo quint Local Health District. ' <br /> made in compliance with San Joaquin Count .Ordinance a City/Town <br /> Exact Site Address Phone <br /> Owner's Nam City-4 J <br /> : 4 <br /> Address License# � Business Phone <br /> Contractor's Name � F Phone�. Emergency <br /> Contractor's Address NO <br /> is Certificate of Workman's'Compensation_ ��uran+(DEEPEN El With SRECONDITIONO DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): <br /> WELL CHLORINATION ❑. WELL ABANDONMENT ❑ OTHER ❑ PUMP WSTALLATION� PUMP REP <br /> REPLACEMENT❑ Sewer Lines Pit P!ivy <br /> DISTANCE TO NEAREST: Septic Tank a e Pit Other <br /> es <br /> Cspool/Seep g , <br /> Sewage Disposai.Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El CABLE TOOL Dia. of Well Excavation <br /> i ❑ INDUSTRIAL Q DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE 11 DRIVEN Gauge of Casing <br /> I ❑ DOMESTIC/PUBLIC l <br /> ❑ GRAVEL PACK Depth of Grout Sea <br /> IRRIGATION ❑ ROTARY Type of Grout <br /> C3 CATHODIC PROTECTION El OTHER Other Information <br /> ❑ DISPOSAL <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor Ip H P. <br /> PUMP INSTALLATION: Type of Pump n1 <br /> I ❑ State Work Done N <br /> PUMP REPLACEMENT: ❑ State Work Done . <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: ' <br /> �� � d <br /> Describe Material and Procedure <br /> 4 <br /> i <br /> one <br /> 1 hereby certify that I have prepared nd ragulatons'licatof the San Joaquin Locah work lllHeall be th District.in cordance with San Joaquin County <br /> ordinances", state laws, and <br /> aws of California.'! <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance compensationIs the work for which this permit <br /> kman <br /> is issued, I shall not employ any person in tore c rtltiesrthe fol owingQ`I certify thsubject toat orthe performs ce ofthe work for which this <br /> (ami <br /> ch <br /> as to <br /> Contractor's hiring or sub-contracting signs <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." r <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> I !i Date: r L1 <br /> Title: <br /> Signed X (Draw plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I pate f <br /> Application Accepted By l <br /> - n <br /> Additional Comments: I Ph a III Final Inspection <br /> Phase 11 Grout Inspection �aieV� <br /> 1 Date Inspection By <br /> Inspection By <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1. ❑ July 1 &Received <br /> REMIT <br /> uly 31 <br /> BILLINGREMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE. e DATE .REMITTED AMOUNT <br /> f <br /> i1 e <br /> FEE I <br /> LESS <br /> PRORATION 11 <br /> PLUS <br /> PENALTY <br /> t OTHER <br /> Eu <br /> OTHER - <br /> - <br /> Received by Date Receipt No <br /> Permit No. Dat Mailed Delivered <br /> m I suance <br /> 1501 E.HAZEL7ON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br /> 201 <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />