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Applications Will Be Processed When Submitted Properly Completed. r� Ta I r,A}�Th"�14p ion. FOR OFFICE USE: APPLICATION' e (For Non -Transferable, Revocable;pen able) PUM ELL ENVIRONMENTAL HEALTH-PERM11UN % 11982 (COMPLETE IN TRIPLICATE) WATER QUALITY. i Application is hereby made tothe San Joaquin Local Health District fora permitto construct a -Min0 a fta'swx ascribed. This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulati��1's�P., _44-b-R1G3qAcal Health District. //Q,, Exact Site Address l +/V- Cit !Town y Owner'sName 4-T—% Phone Address,allCit , - �. y Contractor's Name rte%,` ter' v. License #=f ,Z 31 s Business Phone 4 Contractor's Address /,*0 41/ % 7 +k r Emergency Phone Is Certificate of Workman's_ Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL ❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ WELL CHLORINATION ❑ = WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION 0 PUMP REPAIR ❑ REPLACEMENT ❑ q DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy PUMP REPLACEMENT: PUMP REPAIR: DESTRUCTION OF WELL: Other Type of Pump./� r) H.P. 0-- tate Work Done (?I,//:§ A-1 " 6-- y .. ,,_iv ^, r ❑ State Work Done ` Well Diameter Approximate Depth - - Describe Material and Procedure I hereby certify that I .have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations 6f the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: " I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to,workman's compensation laws of California." e I�w�ill call for a Grout Inspection prior to grouting and a final inspection.- Signed nspection. SI ned X t , f Yh. r g ,:td .�R-,s-r..i-_-+�sri.. � s':�c..•..Title: ,�% a��.a.Ur/ Data: r ' (Draw Plot Plan on Reverse Side)/ Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Wel INTENDED USE a i TYPE OF WELL ❑INDUSTRIAL - ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION x ❑ GRAVEL PACK'.-'; Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL E ❑ OTHER Other Information ❑ GEOPHYSICAL s Surface Seal Installed By: PUMP INSTALLATION: Contractor - PUMP REPLACEMENT: PUMP REPAIR: DESTRUCTION OF WELL: Other Type of Pump./� r) H.P. 0-- tate Work Done (?I,//:§ A-1 " 6-- y .. ,,_iv ^, r ❑ State Work Done ` Well Diameter Approximate Depth - - Describe Material and Procedure I hereby certify that I .have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations 6f the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: " I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to,workman's compensation laws of California." e I�w�ill call for a Grout Inspection prior to grouting and a final inspection.- Signed nspection. SI ned X t , f Yh. r g ,:td .�R-,s-r..i-_-+�sri.. � s':�c..•..Title: ,�% a��.a.Ur/ Data: r ' (Draw Plot Plan on Reverse Side)/ Received by - . ' Dale-. Receipt No.: - Permit No ..Itsuanke Date Mailed _Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 FOR DEPARTMENT USE ONLY PHASE , ` ` `-' r Application Accepted By _ - - Date Additional Comments: Phase II Grout Inspectionhese III final fns ection Inspection By Date Inspection By , Date F -P, Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE - ❑ EACH - ❑ January 1 & Received By January 31 ❑ July 1 & Rec6hi 6d-By':luly 31 BASE EXPLANATION BILLING .. REMITTANCE $ AMOUNT DUE"" REMIT CHECKED DATE DATE REMITTED AMOUNT FEE. [,� t �• LESS PRORATION t ' PLUS y – PENALTY ' - - OTHER OTHER Received by - . ' Dale-. Receipt No.: - Permit No ..Itsuanke Date Mailed _Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201