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T om— Applications Will Be Processed When Submitted Properly Completed.Be sure losign Inerappil-11-1. <br /> APPLICATION <br /> FOR OFFICE USE: <br /> r �k (For Non-Transferable, Revocable,Suspendable) PUMP&WELL t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -F-°- TER QUALITY 2a <br /> (COMPLETE IN TRIPLICATE)_IS-44-Ste'`£-,t`� ELf__W 4� ) Q 2 S ISO <br /> l the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal <br /> made in compliance w'th SanJoaquinCounty Ordinance No.1862 and he rules and regulations of t e an Joaquin Local Health District., <br /> Exact Site Address f D1 Mf' r �� f ��� n � Y + C� <br /> Owner's Name <br /> f hS+<'�[G� - Phone '7 <br /> AddressCity <br /> Contractor's Name <br /> f� jr-CO-5, License#�� Business Phone -��� <br /> Contractor's Address Emergency Phone ! <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> �( No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑❑ OTHERON❑D171 PUMP INSTALLATIONO❑❑ PUMP REPAIR <br /> WELL CHLORINATION 11 WELL ABANDONMENT <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /�0%!� Sewer Lines Pit Privy I <br /> Sewage Disposal Field /�Df Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ` "1 <br /> ❑ DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing ; <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION J9 GRAVEL PACK Depth of Grout Seal _} <br /> ❑ CATHODIC PROTECTION 9 ROTARY Type of Grout D� <br /> ❑ DISPOSAL ❑ OTHER Other Information J <br /> 1:3 GEOPHYSICAL Surface Seal Installed By: Ay <br /> PUMP INSTALLATION: Contractor l� <br /> H.P. <br /> Type of Pump <br /> 4. PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 4- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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 <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 /> I will call for a Grout Ins ection prior to grouting and a fina - spection. <br /> Signed X <br /> (Draw Plot Plan on Rever Side) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I / Date L a- <br /> Application Accepted By L <br /> cnsq <br /> Additional Comments: <br /> Phase II Grout Inspection Phase !II Final Inspection <br /> Date Inspection By Date <br /> Inspection By - <br /> i <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED - <br /> € DATE DATE REMITTED AMOUNT <br /> F <br /> � FEE Fe, I�; 'eLESS <br /> I PRORATION <br /> + PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �Yl� 1.32 <br /> ' <br /> Receipt No. Permit No. Issuance Dat <br /> Received bye Mailed De4ivered <br /> Date <br /> wH1601 F. AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />