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Applications Will Be Processed When Submitted Properly .amp <br /> FOR OFFICE USE: <br /> APPLICATION <br /> LL <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WE <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> WATER QUALITY A.,. •, + u- <br /> ork <br /> (COMPLETE IN TRIPLICATE) ermitto �r. <br /> Application is herebymadetotheSanJoaquinLocal H naCehNo. 1862 and Districtfora the ides and regulators oftheSan Joaquin ltocal Heath District.. <br /> .This application Is <br /> made in compliance with San Joaqu n County Ordinance City/Town <br /> SwZ2 � G�- <br /> Exact Site Address <br /> Phone �� <br /> t, �dO � <br /> 1- <br /> Owner's Naive ' l r: Lo <br /> 3'aim . ; ,.. City Q ) <br /> 6" of x I` <br /> Address k-,'ter �t b" + License# } u' Business Phone <br /> Contractor's Name -� a� - "' �r• I <br /> t, ijl.v ,o ='%Emergency Phone <br /> Contractor's AddressNo Y _ <br /> is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes <br /> TYPE OF WORK (CHECK): NEW WELL�DONMENT ❑ OTHER ITI P �P bESTAUCTION INSTALLATION ❑ PUMP REPAIR <br /> DEE <br /> WELL CHLORINATION 13 WELL X13 <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well � � <br /> INTENDED USE TYPE OF WELL <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia- of Weli Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC _ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION 13 ROTARY Type of Grout <br /> El CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL C1 OTHER -------- <br /> _ surface Seal installed By:" r <br /> ❑ GEOPHYSICAL ` U <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump i. <br /> Work Done -' <br /> PUMP REPLACEMENT: ❑ State Wor , <br /> PUMP REPAIR: 11 State Work Dvne Approximate Depth <br /> DESTRUCT(ON OF WELL: - 'Well Diameter <br /> Describe Material and Procedure -. <br /> 1 <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 signaturecertifies <br /> such mannerowing:"I asto become subject.to workman's compen ay that in the performance of tion laws of Cal forn rkf aor which this �t <br /> is issued, I shall not employ;any person , <br /> Contractor's hiring orsub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, l fall employ persons subject to workman's compensation laws of California." <br /> II <br /> or <br /> o I ecti�n prior to grouting and a final inspection. 4h4 <br /> Title: <br /> 5, Date: <br /> Signed X <br /> (Draw Plot Plano n Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE lDate <br /> Application Accepted By- ` " <br /> Additional Comments: - P ase IH Final Inspection <br /> Phase II Grout Inspection Date <br /> • Inspection,By <br /> Inspection By ' <br /> Date <br /> T ❑ PER SITE ❑ EACH -❑ January Received By January 31 [3 July i &Received By July 31 <br /> Fel IS Due: ❑ ANNUALLY ❑ PER UNIREMIT <br /> BILLING REMITT E $ RMOUNT DUE-" CHECKED - <br /> BASE EXPLANATION GATE ❑ REMITTED AMOUNT <br /> FEE ZS ..CJ <br /> . 3 <br /> LESS <br /> PRORATION <br /> t ! i <br /> "PLUSPENALTY <br /> OTHER <br /> OTHER <br /> OTHER 4 ,.� r }r.. .c -Y <br /> - <br /> ._ ' <br /> � •� Delivered' <br /> Received by Dat f Receipt No. <br /> " Permit No. Issuance Date--� Mailed <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />