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- Will Beprocessed When SuAPP <br /> dproperly <br /> Ap cations L`CATION <br /> FORPFFICV,jSE.,i- (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> LTH PERMIT , <br /> ENV1R0� ENTAL <br /> MG�," SER Nu i � <br /> ` Ilcation is <br /> (COMPLETE IN TRIPLICATE <br /> ?ty4Z les and regulations of the San Joaquin Local Health District. <br /> hereby madeto the San Joaquin Local Health District for a Dere�uto construct�anci/br..il the work herein describ d.This app <br /> Application is he Y 1862 and <br /> made in compliance wjt� f° ,InpCntylO��i ,rlcl City/Town _ Y <br /> Exact Site Address Phone Ems, i <br /> Ad <br /> ' City <br /> Owner's Name 'p �� Phone �J <br /> Address License usiness <br /> Phone 7 � <br /> Contractor's Name 1 Emergency { <br /> Contractor's Address ` ' <br /> � Yes� � No � l� <br /> ❑ RECONDITION❑ DESTRUCTION❑ V <br /> Is Certificate of Workman's Compensation insurance on With SJL ❑ PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL% ❑ PUMP INSTALLATION <br />_ ❑ OTHER <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Y <br /> is 1--- Pit Privy �— <br /> REPLACEMENT❑ -, Sewer Lines .�- Other <br /> DISTANCE TO NEAREST: Septic Tank _. Cesspool/Seepage Pit <br />,3 Sewage Disposal Field �-.�ybyic Domestic W01 <br /> Property Line Private Domestic Well / <br /> TYPE OF WELL ,41y <br /> INTENDED USE ®.CABLE,TOOL__ Dia. of Well Excavation �p Al <br /> ❑ lRIAI •^ - Dia. of Well Casing O <br /> ICIPRIVATE - ❑ DRILLED <br /> DOivl C3 DRIVEN Gauge of Casinggw <br /> D IC/P LIC ❑ GRAVEL PACK Depth of Grout Seal <br /> + 19 IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other information <br /> f C3 OTHER Sur Seal InstallBy. 1 <br /> � <br /> 13 DISPOSAL <br /> � <br /> ❑ GEOPHYSICAL `Contractor yi.P <br /> r <br /> PUMP INSTALLATION: Type of Pump <br /> .r•`. <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done Approximate Depth <br /> PUMP REPAIR: Well Diameter -. <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that.l have-prep <br /> s <br /> Icertif that in the performance of the workforwhofCalspermit r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local HealthDistrict, <br /> Home owner or licensed agent's signature certifies the following:" Y <br /> t to workman's compensation <br /> aw <br /> ubjec <br /> is issued, i shall not employ any person in such manner as to bec me 1 certify that n the performance of theworkfor who h this <br /> t Contractor's hiring or sub-conirace son ng gsubna ject to workman's ture certifies the compensation laws of California." <br /> I permit is issued. I shall employ p z�J <br /> I will all for a Grout specti n p for to grouting and a sinal Inspection. Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> IL <br /> FOR DEPARTMENT USE:ONLY <br /> �J�� <br /> r m J <br /> Date .1s <br /> t PHASE 1 <br /> t Application Accepted F4;' <br /> Additional Comments: Phase 111 Final nspec on <br /> �`,e 11 Grout Inspectio !� � �7 — a <br /> • !� inspection By <br /> ate ' <br /> j Dr.` t <br /> Inspection By rt <br /> REMIT <br /> PER llN4T -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rece�Geo By y 31 <br /> CHECKED <br /> Fee is Due: E] ANNUALLY KILLING - REMITTANCE $ AMOUNT DUE <br /> I REMITTED AMOUNT <br /> BASE F EXPLANATION DATE DATE <br /> ' FEE <br /> 4 <br /> LESS <br /> PRORATION s <br /> PLUS <br /> PENALTY <br /> OTHER <br /> � s - <br /> OTHER <br /> Mailed Delivered <br /> Permit No. I suan a Date GA 95201 _ <br /> Date Receipt No. - 1601 E.HAZELTON AVE.,P.O.Box 2005 -STOCKTON,_ <br /> Received by � <br /> ENVIRONMENTAL HEALTH PERMITlSERVICES _ - <br /> APPLICANT—RETURN ALL GOPIES TO: - `� _ <br />