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IpropComplex" –�� Applications Will Be Prlocessed When Submitted rVf 77n € (For Non-Transferable,Revocable,Suspendabie) , PUMP WELL ENVIRONMENTAL HEALTH PERMIT ,r. WATER QUALITY ^ ' '= application is (COMPLETE IN TRIPLICATE} LocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.7his Application is hereby made to the San Joaquin with San Joaquin County Ordinance No. 1862 and the rules and regulations ity/TownSan Joagl� Local Heaith District. made in compliance w 4f V . 1 ? _ �� Exact Site Address �� g^} Phone . '�' jam• !/7 - 1 City ;� 7 327Owner's Name 1 .. �. ,,T r ` - Address License# -2 Business Phone Contractor's Name Emergency Phone ,5T. No _, JC Contractor's Address �- DESTRUCTION❑ r Is Certificate of Workman's Compensation InsurancDeE�PE IthJSJN C3RECONDITION INSTALLATION❑ PUMP REPAIR❑ TYPE OF WORK (CHECK): NEW WELL WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP 1N REPLACEMENT❑ -- Sewer Privy Sewer Lines Other 1 DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Sewage Disposal Field _ Public Domestic Well Property Line Private Domestic Well TYPE OF WELL /` INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing J S DOMESTIC/PRIVATE ❑ DRIVENGauge of Casing - r ❑ DOMESTIC/PUBLIC GRAVEL PACK Depth of Grout Seal ❑ IRRIGATION ROTARY Type of Grout ❑ CATHODIC PROTECTION It] OTHER Other Information ❑ DISPOSAL Surface Seal Installed By: ❑ GEOPHYSICAL Contractor H.P. PUMP INSTALLATION: Type of Pump ❑ State Work Done U PUMP REPLACEMENT, ❑ State Work Doneapproximate Depth PUMP REPAIR' Well Diameter DESTRUCTION OF WELL: 1 Describe Material and Procedure ' .- lication and that the work will be done in accordance with San Joaquin County -, I hereby certify that I have prepared this app r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. the laws of thisper it \! Home owner or licensed agent's signature certifies the following:`'I certify that in the performance compensation the work for which Cls permit to is issued, I shall not employ any person in such manner as to become I certifsubjecy that in the performance of the work forwhichthis Contractor's hiring or subjoy personng s subject to certifies workman'sfollowing: compensation laws of California." permit is issued, I shall emp y P I will call to G out Insp kion prior to grouting and a final inspection. Date: Title: Signed X (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY 7:7Date TM PHASE I Application Accepted By i inspection he Additional Comments: Phase 1 I Final avI 1 rout Inspection — 1� Date �, Date � Inspection By Inspection By Jut 1 ived By July 31 'PER '❑ PER SITE' ❑ EACH ❑ January 1 &Received By January 31 ❑ y &ReceREMIT Fee Ifs DUe: [3UNIT ANNUALLY $ AMOUNT DUE CHECKEO BILLING REMITTANCE REMITTED DAAMOUNT - BASE EXPLANATION TE DATE /gam FEE LESS PRORATION PLUS PENALTY - OTHER • ' ..Y. OTHER .. J vMailed Delivered Permit No. STOCKTON, Issua cc Date CA95ZOI Receipt No, � ' 1 EHA2ELTON Ave.,P.O.BOY 2009 Received by Date ENVIRONMENTAL HEALTH PERMIT/SERVICES - APPLICANT—RETURN ALL COPIES TO: 160 E.