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Applications Will Be ProcessedWhen Submitted Properly L:omplelea. oeaure Ivsign IIit!MVP111-ativ11. <br /> FOR OFFiCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 2--00_1!51 5_ WATER QUALITY p�p --f3o -,3(, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sanj.4oaq in County Ordinance No. 1862 and th rules and regulations of the San JQaasti��a�th District. <br /> Exact Site Address �1 vti skRo ZflrN W City/Town ��(i1�3 ((//�V <br /> Owner's Name V � Phone <br /> Address LL- City <br /> Contractor's Name C.J�.1 �.1. �� License# j ��0 Business Phone "SS <br /> Contractor's Address 4 Emergency Phone # <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 111_� No �(] <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION[] �\ <br /> WELL CHLORINATIOY.,❑ WELL ABANDONM�,JF VT ❑l ER —PUMP INSTALLATIOR❑ PUMP REPAIR Elr <br /> REPLACEMENT❑ ,: - 1i TC-CT K� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> ;_ Sewage Disposal Field Cesspool/Seepage Pit ' Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> 1 INTENDED USE x TYPE OF WELL <br /> ©-INDUSTRIAL - - a ❑ CABLE TOOL - -Za cJ_WeII.Excavalion-. - —� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLI�.„ _ > ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION -0 GRA�PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTE��TION N-rr0TARY. Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION_' Contractor a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT` _ ❑ State rk Dane <br /> PUMP REPAIR: '"" `�-� --❑.S14e Work Done <br /> DESTRUCTION OF WE�LL: Well jgiameter _Approximate DepTh <br /> Describe Material and Procedure <br /> 1 hereby cetikify that I have prepared this application and-sth f the work w311 be dorie in accordance w4i Sah',loaquin County <br /> ordinances,tstate laws, and rules and reJu.lations of th •,San Joaquin Local Health District. <br /> Home ownenor licensed agent's signature certifies a following:"I certify that in the performance of the work for which this permit <br /> is issued, I s�hall not employ any person in such manner as to become subject to workman's compensation laws of <br /> Contractor's*h i ring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> mit is iss,ed, l shall employ persons subject to workman's compensation laws of California." <br /> 1 11 call fO6 rou Insp i prior to routing and a final inspection. <br /> R•t <br /> Signed X Title: Date: <br /> y (Draw Plot Plan on Reverse Side) <br /> f„1 <br /> FOR DEPARTMENT USE ONLY " <br /> PHASE I /� <br /> Application Accepted By Dateu' <br /> Additional Comments: <br /> . Phase H Grout Inspection Phase,III Final Inspection <br /> Inspection B`-i Date Inspection By Date cah�r�zy�! <br /> et <br /> Fee Is Due: ElAIYN4JALLY El PER UNIT El PER SITE 11 EACH El January 1 &Receivedlvy Ja 41ry 31 ❑ July 1 &Received By July 31 <br /> t--, <br /> REMIT <br /> BILLING REMITTANCE $ <br /> AMO <br /> 'BASE EXPLANATION UNT DUE CHECKED <br /> DATE DATE REMITTED *AMOUNT <br /> i <br /> FEE w <br /> LESS f <br /> PRORATION a <br /> 1 <br /> PLUS <br /> PENALTY <br /> OTHER ` ' <br /> OTHER <br /> `*v <br /> '# P <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />