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'-Applications Will Be Processed When Submitted Property omp e e <br /> APPLICATIONFOR OFFICE USE: `_ <br /> .�: (For Non-Transferable, Revocable;Suspendbble) PUMP&WELL � <br /> _ ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District;or permit to construct and/or install the work herein described.This application Is <br /> Application is hereby made to the San Joaquin <br /> y Ordinance No. 1862 and t rules and regulations /of th Townson Joaquin Local He Dlstrlc . <br /> made in compliance with San-Joaquin CountCity <br /> t <br /> Exact Site Address 3-7 t <br /> C3 sPhone ' <br /> Owner's Name , City i <br /> Address $� <br /> r 3 Business Phone� _V 3Y r 3 <br /> ti l <br /> Contractor's Name License# <br /> — <br /> Contractor's Addr4� �' Emergency Phone <br /> No <br /> is Certificate of Workman's Compensation in <br /> on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION L�� PUMP REPAIR❑ ^I <br /> REPLACEMENT❑ .6 C. Pit Privy <br /> a�t' <br /> > � Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank!d Cesspool/Seepage Pit Other i <br /> Sewage Disposal Field <br /> , <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> xcavation <br /> Dia. of Well E <br /> 11 INDUSTRIAL <br /> 11 CABLE TOOL 111 <br /> 13 DRILLED - Dia. of Well Casing <br /> L 'DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> C1DOMESTIC/PUBLIC Depth of Grout Seal <br /> 13 IRRIGATION ❑ GRAVEL PACK f { <br /> COTARY Type of Grout <br /> C1 CATHODIC PROTECTION Other Information e� <br /> ❑ DISPOSAL ❑ OTHER <br /> Surface Seal Installed By: _J <br /> ❑ GEOPHYSICAL . <br /> PUMP INSTALLATION: Y Contrac or. <br /> H.P. » <br /> Type of Pump _ r <br /> PUMP REPLACEMENT:. ❑ State Work Done <br /> + ❑ State Work Done <br /> ! PUMP REPAIR: Approximate Depth <br /> :DESTRUCTION OF WELL: Wel! Diameter <br /> { Describe Material and Procedure <br /> y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> "'ordinances, stale laws, and rules and regulations of the San Joaquin Local Health District. I,.Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permierson in such manner as to become subjectto workman's compensation laws of California. <br /> r is issued, I sha11 not employ any p <br /> certifies the following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature <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.414 <br /> t ` Ky <br /> Title: <br /> . Date. o <br /> Signed X - -- (Draw Plot Plan on Reverse Side) <br /> I <br /> FOR DEPARTMENT USE ONLY + �-=—n�--rS <br /> PHASE I Date f� <br /> Application Accepted By 4ti <br /> Additional Comments: ` ase III ns c ion j <br /> P ase.Il Grout Inspection x_! r <br /> !Inspection By 1]ate � � s ' <br /> Inspection By <br /> yWc ❑ 1 &Received By January 31 ; ❑ July-1 &,Received By July 31 <br /> UALLY PER UNIT El PER SITE ❑ EACH January REMIT <br /> Fee Is Due: C1 ANN <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> 00 <br /> FEE. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER . <br /> Issuance Date Mailed Delivered <br /> Received by ate <br /> Receipt No. - -- -PermiS No,- <br /> 1501 E.HAZELTON AVE.,P.O.90:2009 STOCKTON,CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />