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_. .. �_ <br /> roperty�;omplvxwv <br /> Applications Will Be Processed When SuAPPL`CATI-ON <br /> r. .� � � endable) PUMP&WEI.I- <br /> ,.oR OFFICE USE: (For Non-Transferable, Revocable,Susp <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY - t , f..�' :.,'tom ` application is <br /> all the wor <br /> (COMPLETE IN TRIPLICATE) Joaquin Local Health District. <br /> hereby made tot San Joaquin Local Health Districtfora Phe ides and regulations s oftthe San Jo aerein describedp This <br /> Application is he Y = t <br /> City/Town <br /> made in compliance with San Joaquin County Ordinance No•j� an # <br /> to 10 <br /> Exact Site Address 445 W Phone <br /> . �,�. <br /> Owner's Name Y t,Gy(' , City e <br /> ABusiness`Phone <br /> Address " ) <br /> License <br /> Contractor's Name Emergency Phone <br /> Contractor's Address Y ? Yes No <br /> Compensation insurance on File With SJLHD ❑ DESTRUCTION❑ �- <br /> Is Certificate of Workman's Comp _-_ - ❑ RECONDITION PUMP REPAIR <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN <br /> WELL CHLORINATION C3WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION <br /> i <br /> REPLACEMENT❑. - _ Sewer Lines Pit Privy <br /> Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br />' i Sewage Disposal Field Public.Domestic Well A <br /> t Property Line Private Domestic Well <br /> i i TYPE OF WELL <br /> INTENDED USE ❑ CABLE TOOL Dia. Of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing I <br /> _ <br /> M DOMESTIC/PRIVATE 11 DRILLED❑ DRIVEN Gauge of Casing <br /> It ❑ DOMESTIC/PUBLIC Depth of Grout Seal u <br /> 13❑ IRRIGATION GRAVEL PACK <br /> ❑ ROTARY Type of Grout b <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other information <br /> ❑ DISPOSAL a Surface Seal Installed By: <br /> t ❑ GEOPHYSICALWater S Stems <br /> Contractor 1. <br /> Moorman' S KID. <br /> PUMP INSTALLATION: T pe of Pump <br /> State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done Approximate Depth <br /> ' PUMP REPAIR: <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> rthat l have prepared this application and that rdance with San Joaquin County <br /> the work will be done in acco <br /> r <br /> I hereby certify <br /> I certify that in the performance lensationfor <br /> laws of California." <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> y Home owner or licensed agenany person s certifies <br /> manneras tobecomesubject to,workman s P <br /> is issued, I shall not employ i certif that in the performance of thew ork lorwhich this♦ <br /> persons subject to workman's compensation laws of California." <br /> r <br /> contractor's hiring or sub-co signature certifies the following:" Y <br /> permit is issued, 1 shall employ P <br /> I will call for a Grout Inspection prior to grouting and a final inspection. pate: <br /> Title: , <br /> Signed X {Draw Plot Plan on Reverse Side) , <br /> n FOR DEPARTMENT USE ONLY <br /> Date 4��'3-� <br /> PHASE <br /> Application Accepted Y .. <br /> Additional Comment a ;II Fi Inspection f6,_� � <br /> Phase II Grout Inspection Date <br /> Date Inspection By <br /> Inspection Byy.lanuary 31Jul 1 &Received By July 31 <br /> REMIT <br /> Fee is Due: 13 ANNUALLY -❑ PER UNIT= ❑ PER SITE <br /> EACH ❑ January t &Receive$d BAMOUNT'DUE - CHECKED <br /> BILLING REMITTANCE REMITTED9 AMOUNT <br /> - BASE - EXPLANATION DATE DATE <br /> f <br /> FEELESS <br /> � _ <br /> PRORATION Z <br /> p•l <br /> PLUS <br /> PENALTY - r <br /> OTHER <br /> r OTHER <br /> ` , - Issuanc Date Mailed A. Deligered <br /> .Permit No. - STOCKTON,CA 95201 <br /> Received by ate <br /> D - Receipt No.'--f` � 1601 E.HAZELTON AVE..P.O.BoK 2009 <br /> "� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />