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Ll <br /> g. !'Applications Will Be Processed When Submitted Properly Completed.8e �rTo1 r9hEyA�Oat� s <br /> FOR OFFICE-USE:Y APPLICATION <br /> (For Non-Transterable, Revocable,Susple) = `� <br /> &WELL r <br /> ENVIRONMENTAL HEALTH PE <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 1 ��� '� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instolpgt1 �rpyffi'd�er n described.This appkcation is l <br /> made in compliance with San Joaquin County Ordinance o. 1 2 and ter I s and regulations of thin Joaquin Local Health District, <br /> Exact Site Address <br /> �(� �!� City/Town L s+M i +COrt! <br /> Owner's Name S Phone <br /> Address City -�.—pp�p <br /> " <br /> Contractor's Name %1 D,. C�' 't'` License#r�79-0 Business Phone iJ�f12207 �— <br /> �C3 Emergency Phon <br /> �'j,t�/ e ��' <br /> Contractor's Address _ /Y�j No .� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El DEEPEN DESTRUCTION <br /> WELL CHLORINATION 11 WELL ABANDONMENT El OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT M <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY 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 A S L. <br /> PUMP REPAIR: ❑ State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I hereby certify 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which 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 is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will r a Grout Inspeclip n.prior o grouting and a final inspec' - <br /> I Signed X <br /> Title: Date: <br /> (Draw Plot Plan on everse Side) <br /> �nFOR DEPARTMENT USE ONLY <br /> PHASE ,e� io—ts-&D <br /> Application Accepted By Date y <br /> Additional Comments: z WV <br /> Phase II Grout Inspection I Final Inspection <br /> Inspection By � Date InspectionZc�eived <br /> Date <br /> Fee Is Dile: 13 ANNUALLY <br /> ,1 ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 By January 31 ❑ July 1 &ReceiveRd By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> }�, <br /> FEE T 9 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> fn �4, j o j� '�6 ( If �. <br /> Received by D to Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />