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Applications Will Be Processed When Submitted Properly Completed.'Be SureTo-Sign li anon <br /> FOR OFFICE USFV APPLICATION 1980 <br /> (For Non-Transferable, Revocable,Suspendable) SAN JI0 � LL <br /> � -' � <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and rept_ i of the San Joaquin Local Health District. <br /> Exact Site Address �Ctt �yKt+ �U'�►-rte o CBS C�Lwv�� �`'�City/Town <br /> Owner's Name rY e Phone ?I-4r - .3 U <br /> Address C,-r y e5 City GSc_c� t' <br /> Contractor's Name tiF 1Zi f�11 i'tZ 12�f1e-T«^ License# �A yBusiness Phone S� Cn <br /> Contractor's Address CA,Ce JC1 clued �J Emergency Phone aG_ 11 0 <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes_XNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 1:1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER El PUMP O <br /> PUMP INSTALLATION ❑ PUMP REPAIR i <br /> REPLACEMENTIa I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy <br /> �� Sewage Disposal Field Cesspool/Seepage Pit Other <br /> �G IN P4-11 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 /> �❑r DOMESTIC/PUBLIC I ❑ DRIVEN Gauge of Casing <br /> 1+�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: y <br /> PUMP INSTALLATION: Contractor u 1 <br /> Type of Pump De e v I H.P. r'/S 4 � <br /> PUMP REPLACEMENT: 'State Work Done �+' S r tL�Y l.UCh�CV- <br /> PUMP REPAIR: - B-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure . a <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 call for a Grout Inspection prior to grouting and a final inspection. <br /> ' Signed X At Title: 72-4!!:W ep-Iz� Sy— Date: Xr) <br /> (Draw Plat Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> F' Additional Comments: <br /> Phase II Grout Inspectionase,-111 Final Inspection <br /> Inspection By Date Inspection Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> - REMIT <br /> RASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE — dl�t <br /> LESS <br /> ( PRORATION ^ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i OTHER <br /> Received by Date . Receipt No. `emit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 _ STOCKTON,CA 95201 <br />