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d ProperlyCOMPIL <br /> Applications Will.Be Processed When SubAmittPLICATION <br /> FOR OFFICE USE: (For Non-Transterable,Revocable, Susp <br /> endable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY, T,, �1 tO i;l - °' •• 'l lication is <br /> L.; <br /> (COMPLETE IN TRIPLICATE) <br /> 1 2rnd the rules and're ui 'o of•the San J aquin L al Health District.• <br /> Application is hereby madeto the San Joaquin Local Health Distric'tiara permifto construct and/or install the work herein described. Is <br /> App Or ' ance No <br /> made in compliance with S n J aquin Co my 2. ity/Town <br /> Exact Site Address + ,$. Phone:' <br /> owner's-Name City <br /> Address License <br /> Busioess Phone'3 <br /> Phone.. ..•. ;ry}':�—^— <br /> Contractor's Name F., Emergency p <br /> Contractor's Address <br /> _ N o �— <br /> Is Certificate of Workman's 'compensation LlnsurancDeEEnPE With SJRL �NDITION STRUCTION❑' .w <br /> TYPE OF.WORK (CHECK): <br />' TION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION© PUMP REPAIR❑ <br /> WELL CHLORINATION ! _- <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines other <br /> DISTANCE TO NEAREST: Septic Tank' Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Linele�Private Domestic Well - ,f <br /> TYPE OF WELL ' <br /> INTENDED USE CABLE TOOL Dia. of Well Excavation rr <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> [I 11 <br /> - <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing r <br /> DOMESTIC/PUBLIC `GRAVEL PACK Depth of Grout Seal , <br /> ❑ IRRIGATION �f ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑\OTHER Other information <br /> ❑ DISPOSAL Suftce Seal installed By: ; <br /> " ❑ GEOPHYSICAL:. <br /> } <br /> PUMP INSTALLATION: Contractor H.P.Type of Pump <br /> i r ❑ State Work Done <br /> PUMP REPLACEMENT: ' 0 State Work Done <br /> PUMP REPAIR: __ _ _ °Approximate Depth -�- <br /> f ^Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> r' t I have pre this application and that the work will be <br /> l7istrictGcordance with San Joaquin County <br /> I hereby certify that p a- .. <br /> 1 certify that in the performance of thew onorW of Califo hich this permit <br /> a�tordinances,state-laws, and rules and regulations of the San Joaquin Local <br /> Home owner or licensed agena�s �persooen such mannerrtilies the )as1to become subject to workman's comp <br /> I, is issued, I shall not employ following', certify in the <br /> Contractor's hiring or sub-contracting signaturct to workmanIscompensationl wstof California of the work for which this . <br /> I 1 <br /> permit is issued, I hall empla�+ per S sae <br /> j ill 11 for Gr ut Insp talon nt�ard a final inspection. f <br /> Date <br /> Title. <br /> Signed X (Draw Plot Plan on Reverse Sid <br /> i <br /> # OR DEPARTMENT USE ONLY <br /> Date <br /> I PHASE I �f1QCu 9 i <br /> I Application Accepted By <br /> Additional comments: p ase 111 Final inspection <br /> phase 11 Grout Inspection Date <br /> Date <br /> tDate r'1��2 Inspection <br /> inspection By By <br /> I � REMIT <br /> Fee IsDUe: ❑ ANNUALLY "•'❑ PER UNIT ❑ PER'SITE -❑ EACH REMITTANCE t &Receiv By 35AMO<OTJDUE uly 1 RecelvC�dECKEDBy y 31 <br /> s i r ..�13ILLING t AMOUNT <br /> EXPLANATION DATE REMITTED, <br /> + 'BASE'-- DATE <br /> r FEELESS <br /> a <br /> S PRORATION { <br /> PLUS <br /> PENALTY- <br /> OTHER <br /> OTHER , <br /> L �� Iss nce D e, Mailed'-. Delivered. <br /> ermil No. <br /> Received by= <br /> • --6 Date H^"^—"'-"'�Receipt No: -�- 1601 E.HAZELTON AVE.,P.O.aox 1fl09 STOCKTON,CA 86201 <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITISERVICES <br />