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Applications Will Be Processed When Submitted Properly Completed. Be §ftkoSign The ApplicKtic-QW7 <br /> FOR OFFICE USE: APPLICATION jr�� ¢ <br /> (For Non-Transferable, Revocable,Suspendable 9 n <br /> ENVIRONMENTAL HEALTH PERMIT$AN JOAQUN <br /> MP& ELL k <br /> WATER QUALITY H � <br /> (COMPLETE IN TRIPLICATE) � D/s`rpp''^^COPAL1 t <br /> Appl ication is hereby made to the San Joaquin Local Health Districtfora permit to ci#Pstru.ct and/or install the work herein d O'Fed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the Luless and regulations of the San Joaquin Local Health District. p <br /> Exact Site Address 3 City/Town � p a <br /> Owner's Name > l/tI! _ Phone 7�7 Z�! Z <br /> Address �r � © City ,. _A e - <br /> Contractor's Name JPf9�A License# 35zha�s Business Phone <br /> Contractor's Address Emergency Phone '�.fr�°�Sl <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-E] ' PUMP INSTALLATION K PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 I <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL ❑ CABLE TOOL _ Dia. of Well Excavation 7 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information \ '_ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: v <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump H:P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 4 <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 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 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 /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this "l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection or to grouting and a final inspection. <br /> Signed X / Title: T Date: <br /> (Draw Plot Plan on Reverse Side v, � , F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f/ <br /> Application Accepted By 1` �� - "`� q Date <br /> Additional Comments: - ¢ <br /> Phase 11 Grout Inspection /Phase III Fi al Inspection i <br /> Inspection By Date Inspection By c 1a _S. X�te 3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 '�F <br /> BILLING REMITTANCE $ REMIT <br /> BASE , EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> c/S d 4fy-vc <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> b <br /> OTHER <br /> i <br /> O.S—!/L <br /> Received by Date Receipt No. Permit No, - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOK 2009 STQGNTON,CA 95201 <br />