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-!' Applications Will Be Processed When Submitted ProperlyCompleted. tie ur loatgn ne,�,N,r.o.�.,,.• <br /> FOR OFFICE USE: ' :- APPLICATION <br /> i� � ��' <br /> (For Non-Transferable, Revocable,Suspendable) ZP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ''^ <br /> F r = WATER QUALITY - <br /> .(COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin L"ocal Heaith District for a permitto construct and/or install the work,herein described.This application is <br /> I made in compliancewitta: an Joat uin Eouniy�rdinance�No.�1 62 and t r les and.regulations of the San Jo�q}iL�al�te th District. <br /> ��1'r I —� City7 <br /> Exact Site Address <br /> Phone <br /> Owner's Name - <br /> +r s City <br /> - Address .. Business Phone_ r <br /> (cen <br /> se <br /> Contractor's Name ~ <br /> Contractor's Address l _ - Emergency Phone <br /> I Is Certificate of Workmanm <br /> 's Copensation lnsur ce on File With SJLHD? Yes No — <br /> TYPEOF WORK-(CIIECK)� NEW WELL DEEPEN.❑ HE'CONDITION❑• DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT'[] OTHER ❑ PUMP INSTALLATION ®PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> d rt Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �.. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> t Property Lin Public Domestic Well <br /> eLL Private Domestic-Well�4 <br /> r INTENDED USE TYPE OF WELL Y` <br /> ❑ CABLE TOOL Dia. of Well Excavation f Z'/ we-4 <br /> 11 INDUSTRIAL <br /> ®'COMESTIC/PRIVATE I! Q- TffLLED Dia. of Well Casing. r G <br /> ❑ DOMESTIC/PUBLIC DRIVEN , + Gauge of Casing <br /> ❑ IRRIGATION ❑ <br /> , GFJA <br /> VEL PACK Depth of Grout Seal LL <br /> 11 CATHODIC PROTECTION ? ROTARY` Type of Grout" <br /> ¢ 1:1DISPOSALt ii ❑ OTHER Other Information <br /> :. <br /> ❑ GEOPHYSICAL SuKace Sea Ins (led By: <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> r PUMP REPLACEMENT: i, ❑ State Work Done <br /> PUMP REPAIR: ' ❑ State Work Done <br /> i� Approximate Depth: <br /> DESTRUCTION OF WELL: Well Diameter <br /> / 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 regolatioris of the San.Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the iQllowing:"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-theiolloriring:1 certify that in the performan.cg of the work for which this <br /> permit is issued, I shall empioy persons subject to workman's compensation laws of'California." <br /> I w' II fora,. nspection prior to grouting and a finl inspection. <br /> III <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on.Revers Side) <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I .� Date 7,9 <br /> i <br /> Accepted By <br /> Application <br /> Additional Comments: <br /> Phase II Grout Inspection ase inahlnspection <br /> Inspection By Date spe tion By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ an ry edeived By January 31 ❑ July i &Received By July 31 <br /> - REMIT <br /> RASE EXPLANATION BILLING tE TT NC $ AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> T - ' <br /> OTHER <br /> OTHER D <br /> .Received by �lDate Receipt No.' ermit No. is anc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 0 <br />