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`.Applications Will Be Processed When Submitted Properly Compieiea.%teeo-- -y• <br /> APPLICATION <br /> FOR OFFICE USE:: = <br /> (For Non-Transferable, Revocable, Suspendable) pump&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Z o L S. ;IVY 9f WATER QUALITY r <br /> (COMPLETE IN TRIPLICATE) f <br /> Application is hereby made to the San Joaquin Local Health Distnctfor a permit to construct and/or <br /> ons oftthe 5 thework focal HealdthThis <br /> Disiralpplication is <br /> made in compliant an J aquirt County Or na e No.1862 an �y11 City/Town td�� r <br /> Exact Site Addre F.::z, _ 0 <br /> Phone <br /> Ifte <br /> Owner's Name City ¢ <br /> Address %VV License Business Phone_. __ ^- <br /> Contractor's Name Emergency Phone a y i <br /> Contractor's Address No �. J <br /> is Certificate of Workman's Compensation lnsurraa on File With SJLHD? Yes 1 <br /> TYPE OF WORK (CHECK): NEW W AaAN—ABANDONMENT ❑EEPEN ❑ OTH RRECONDITION <br /> ❑ ITI PU❑P INSTALLATION <br /> ESTRUCTION El WELL <br /> ❑ PUMP REPAIR❑ .7 <br /> WELL CHLORINATION ❑. WE ter" <br /> REPLACEMENT❑ r Lines SeweQ d �" Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> /r <br /> Sewage Disposal Field_ Cesspool/Seepage Pit p <br /> I` Private Domestic Well Public Domestic Well <br /> Property Line <br /> i INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f13 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE [] DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION 11 GRAVEL PACK _ p •� , <br /> ROTARY Type of Grout <br /> j ❑ CATHODIC PROTECTION Other Information <br /> El DISPOSAL 1:1 OTHER <br /> Surface Seai Installed By:, <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL:. Well Diameter <br /> Describe Material and Procedure <br /> this application <br /> the San JoahquirloLocalllHealtlbe h Qistricone in tcordance with San Joaquin County <br /> I hereby certify that I have prepared <br /> ordinances, state laws, and rules and regulations _ <br /> Home owner or licensed agent's signature <br /> such mannercertifies the lowinas togbecome subject to workm n's compensationy that in the performance of the work f laws of Cal fornia.t <br /> is issued, I shall not employ any person <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 11 call for a Grout pri to grouting and a final inspection. Data: <br /> Title: <br /> Signed r 1 <br /> k (Draw Plot Plan on Reverse Side) <br /> ORD PARTMEN USE ONLY <br /> PHASE I ® Date_,R///<Fly <br /> Application Accepted By-' <br /> Additional Comments: ha al Inspection <br /> Ph a a II Grout inspection 4��' Date <br /> i. Date <br /> 6 Inspection <br /> ! By <br /> Inspection By <br /> PER UNIT PER SITE ❑ EACH <br /> C3 January 1 8 Received By January 31 ❑ Su1y 1 &Received By July 31 <br /> Fee is Due: ❑ ANNUALLY [3 PER <br /> BILLING REMITTANCE $ AMOUNT DUECHECKED <br /> —BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> FEE <br /> t LESS <br /> o�'i iavl Yt^Gr Iry dr;fJir} <br /> i PRORATION <br /> PLUS { <br /> PENALTY <br /> F OTHER <br /> OTHER <br /> I ' l Permit No- Issuance 4ate Mailed Delivered <br /> Received by - '^--Date ,.. ',Receipt No. CA 95201 <br /> 1601 E.HAZELTON-AVE.,P.O.Box 2009' .STOCKTON, <br /> APPLICANT—RETURN ALL COPIES TOI `ENVIRONMENTAL HEALTHIPERMITISERVICES Jam- <br />