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FOP OFFICE USE: APPLICATiON <br /> 1981 <br /> (For Non-Transferable, Revocable, SUSPendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP ex 1N1=11 <br /> GAN <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY H[.J--J-AVtTI [L) ; , <br /> Health District for a permit construct and/or install the work herein described.This application is <br /> Application,ication is hereby made to the San Joaquin Local I F� �, <br /> mad�,,in compliance with San Joaquin County Ordinance No 1862 and the rules and regulations of the San i <br /> Exact Site Address Cioaq.um Local Health District. <br /> ty/T.v,, <br /> Owner's Name Phone <br /> A <br /> Address <br /> 1A <br /> Contractor's NameC-) License # Buskness P"ne 3 <br /> Contractor's <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? . Yes 4.�-- No <br /> TYPE OF WORK (CHECK]: <br /> NEW WELL 1:1 DEEPEN E] RECONDITION El OFSTRUCTIONO <br /> WELL CHLORINATION E1WELL ABANDONMENT El OTHER El PUIVIP INSTALLATION ❑ PUMP REPAIR Off- <br /> REPLACEMENT 19 <br /> DISTANCE TO NEAREST: Septic Tank _/—„ Sewer Lines 0G - P4 Privy <br /> Sewage Disposal Field Cesspool/Seepage P4 Other—___ <br /> Property Line— Private Domestic Well --- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> XfNDUSTRIAL [TCABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> (R DOMESTIC/PUBLIC <br /> ,DRIVEN Gauge of Casing <br /> El IRRIGATION fikQRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION El ROTARY Type of Grout <br /> E] DISPOSAL El OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -5 <br /> PUMP REPLACEMENT: State Work Done -P� — <br /> PUMP REPAIR: El State Work Done <br /> DESTRUCTION OF WELL; Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby codify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or,licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Ir <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which t4is <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ll <br /> C-- i <br /> Title: Date: c <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> V� <br /> PHASE <br /> Apply atIion Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha�XIII Final Inspection <br /> Inspection By Date Inspection By,17.�e , Dale ... <br /> Fee Is Due: El ANNUALLY 11111 El PER UNIT Ll PER SITE L1 EACH LJ January 1 &Received By January 31 El July 1 &Received By Jifly 3 1 <br /> BASE EXPI-ANATION BILLING REMITTANCE $ AMO�-INT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FFF C� <br /> LESS <br /> PRORATION <br /> PLO"; <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Istuance Dare Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL'HEALTH'PERMITISERVICES 1601'E.HAZELTON AVE.,P.O.Sox.2009 STbCKTON,'CA-9-5201 <br /> PLATE 22 <br />