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atlons Will Be Processed When Submitted Prop Y COnlP'll <br /> APPLICATION <br /> FOR OFFICE USE: �O i� (For Non-Transieragle,Revocable,Suspendable} / PUMP &WELL , <br /> 1 Ian. 3 l <br /> ENVIRONMENTAL.HEALTPERMIT <br /> H: <br /> ' WATER QUALITY ,.� <br /> (COMPLETE IN TRIPLICATE) <br /> etotheSanJoaquinLocalNealthDistrictforapermittoconstructand/or installtheworkhereindescribed.Thisapplicatto ,A M <br /> Application is hereby mad a:a �',,wa;. <br /> 1. <br /> LO <br /> CitylTown s .� t <br /> with San Joaquin-County Ordinance No. 1862 and the� sand regulations of the San Joaquinal���� istnct <br /> made in compliance v ai <br /> Exact Site Address•- , _ } r. Phone , <br /> City r <br /> Owner's Nae <br /> m <br /> Business Phone <br /> Address <br /> License#� <br /> Contractor's NameF p+s ;Emergency Phone <br /> No <br /> Contractor's Address �—— <br /> 1s Certificate of Workman's Compensation Insurance EEPEN�Ith SRECONDITION�STRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> ❑ OTHER ❑ PUMP INSTALLATION 13 _UMP REPAIR.-�=y <br /> REPLACEMENT 11 Pit Privy <br /> Septic Tank Sewer Lines Other <br /> DISTANCE TO NEAREST: Sep Cesspool/Seepage Pik , <br /> Sewage Disposal Field Public Domestic Well <br /> Property.Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE ❑ CABLE TOOL Dia.-Of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> (a DOMESTIC/PRIVATE [3 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK - Depth of Grout Seal , <br /> } ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> E ❑ CATHODIC PROTECTION 13 OTHER Other Information <br /> 3 11DISPOSAL Surface Seal Install d By: <br /> ❑ GEOPHYSICAL <br /> 1 Contractor H P <br /> PUMP INSTALLATION:. Type of Pump <br /> ❑ State Work Done <br /> I PUMP REPLACEMENT: fio State Work Done Approximate Depth <br /> PUMP REPAIR: . Well Diameter J <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> t. <br /> t application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this <br /> I certif that in the performance of the worktorwhich this permit <br /> ' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents signature certifies the following:" certifyt to <br /> that <br /> issued, l shall not employ any person in such manner as tot ow nme'I certifsubjec y that iionrthe performance of helwork forwhiaws of ochthis <br /> Contractor's hiring or sub-contracting signature <br /> cert.ifioe thekrnafollowing: <br /> compensation laws of California." <br /> permit is issued, I shall employ p <br /> 1 11 call far a Grout inspectF`n io t grouti nd P Date: <br /> a le: <br /> Signed raw Plot n on Reverse Side}. <br /> a1 inspection. <br /> FOR DEPARTMENT USE ONLY%1� - - . Ujl� OLAQ <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: h III Final Inspection 40— I"6 F <br /> ha a ll Grout Inspection Date <br /> By OI <br /> inspection <br /> Date inspection By <br /> {; UNIT <br /> 31 <br /> Fee Is l;?ue: ANNUA <br /> ❑ LLY ❑ PER ❑ PER EACH REMI❑TTANCEy 1 &Received MO T nUE CHECKED <br /> By January 31 AMOUNT <br /> REMIT <br /> ❑ &Received <br /> SITE <br /> BILLING ATE REMITTED AMOUNT <br /> - BASE EXPLANATION DATE DQ - <br /> FEE `-✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> OTHER <br /> /6 <br /> OTHER i � y� <br /> i lJMailed Delivered <br /> -Permit No-._ _ lssu nce Date P.O.aux 2009 STOGKTON,CA 95201 <br /> Received by <br /> Y DA1e _ Receipt No. 1661 E.HAZELTON AVE..- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI5ERVIC <br />