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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Si rle Appf cato.� - f4 <br /> FOR OFFICE USE: APPLICATION MAR 9 J f <br /> (For Non-Transierable, Revocable, Suspendabfe) I PAL (f <br /> ENVIRONMENTAL HEALTH PERMIT SAN PUMP cC A LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ��egL����577--Lpp!®nn�AL <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct acrd/or install thework herein describe."ftiistaXplication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin L cal Health District" <br /> Exact Site Address Z 9 ed.Wy I S / City/Town <br /> Owner's Name / �J(S /' Phone *61 6 <br /> Address Z-9gS �—: <br /> �zt< <br /> ,,,r���City s <br /> Contractor's Name License f�..r�c.+ / Busi ss Phone <br /> Contractor's Address ' �. Emergency Psh�on?, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI <br /> REPLACEMENT O <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field s - CesspoolLSeepage Pit --« Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation } <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth..of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H-P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: VkState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure O <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> �r <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 forwhich this permit <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 forwhich this <br /> permit i issued, I shall employ p subject to workman's compensation laws of California." <br /> I w' I a Grout Inspecti pr' o grouting and a final inspec' n. <br /> Signed XTitle: -�� Date: <br /> (Draw Plot Plan on Reverse Siddr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByX2A,2�� 3— 7 t <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase final I ection <br /> Inspection By Date Inspection By -�� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT +' <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE bb <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> ` e <br /> P <br /> OTHER ' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;4AR952'0i <br />