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perly Uor"Plut— <br /> Applications Will Be Processed When SuAPPL�CATIQN PUMP&WALL ' <br /> endable) ' <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Susp �y <br /> n.,. <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY application is <br /> WATER Q .. <br /> COMPLETE IN TRIPLICATE) nJoaquinLocalliealthDistrictforapermittoconstructand/orinstallthework herein described.This ri <br /> ( made to the Sa and the rules and regulations of the San aqui 'L Cal Health District. <br /> Application is hereby Ordina a No. City/Town (� / <br /> made in compliance with �cbln COLI <br /> Exact Site Address Phone <br /> s s / t. ity <br /> Owne('s Namin 'Phone� ` <br /> Address License# <br /> IR <br /> ,- <br /> Contractor's Name Emergency Phone Z t - No � - <br /> Contractor's Address Yes } <br /> ❑ RECONDITION❑ DESTRUCTION❑ PUMP REPAIR❑ <br /> is Certificate of Workman's Compensation ins rancDeEoEPE-With SJL ❑ PUMP INSTALLATION <br /> TYPE OF WORK(CHECK): NEW WEti ❑ —. OTHER <br /> # WELL CHLORINATION ❑ WELL ABANDONMENT <br /> Sewer Lines Pit Privy®Q her <br /> i REPLACEMENT❑ vol/Seepage Pit <br /> Cessp <br /> r DISTANCE TO NEAREST ..w Sewtage Dispo.ssr�aal Field - Public Domestic Well <br /> Lille <br /> Private Domestic Well <br /> Property �► /j� <br /> TYPE OF WELL / <br /> CABLE TOOL Dia. of Well Excavation <br /> o INTEN ❑ <br /> DED USE Dia.of Well Casing <br /> ❑ INDUSTRIAL DRILLED <br /> KnCIRRIGATION OMESTIC/PRIVATEDRIVEN Gauge Of Casing <br /> Depth of Grout SealOMESTIC/PUBLIC ❑ GRAVELPACK Type of Grout <br /> ❑ CATHODIC PROTECTION pROTARY - s Other Information / <br /> f OTHER ..Surfa a al I stalled B <br /> ❑ DISPOSAL. ,s <br /> ❑ GEOPHYSICAL Contractor - H.P. <br /> PUMP INSTALLATION: Type of Pump x <br /> • ❑ State Work Done � <br /> PUMP REPLACEMENT: ❑ State Work Do w pproximate Depth <br /> PUMP REPAIR' Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> lication and that the work will be done in accordance with San Joaquin County <br /> I prepared this app Joaquin Local Health District. <br /> L hereby certify that I have <br /> ordinances,state laws, and rules and regu;ations of the San <br /> er or licensed agent's signature certifies the following:"i certify that in the performance of the work for which this perms <br /> i Home own person in such manner as to become subject to workman's compensation jaws of Californias <br /> is issued, i shall not employ any p 1 certify that in the performance of the work for which this <br /> 10 persons subject to workman's compensation laws of Calitorriia." <br /> Contraciar's hiring or sub-contracting signature certifies the following: 1 <br /> t permit is issued, I shall employ p grouting and a llnal inspectio <br /> 1 it I for r t inspection prior to fd Date: <br /> Title: <br /> Signed X l (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> p 1 l`l <br /> Date <br /> PHASE I I `y1ti'�.Ct� o I r.r <br /> Application Accepted By wit b <br /> ase i Inspe n <br /> Additional Comments: <br /> p 11 Grout Inspection I � Inspectioh 8 e <br /> y �+- <br /> Date Jul s <br /> inspection B January31 ❑ July t &R ceived 6y Y <br /> EACH ❑ <br /> JanuaryJ1 R Received y REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE $ AMOUNT DUE CHECKED <br /> a1LLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE a Q <br /> f FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ /{_ q Mailed <br /> d Delivered <br /> - <br /> } Permit No. I suanc ate <br /> Received by Date <br /> Receipt No 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />