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Applicatibris�Vill Be Processed When Submitted Properly Completed. Be Sure Tit <br /> 4 ;aIn — � <br /> FOR OFFICE USE: APPLICATION <br /> Y <br /> UU <br /> �` I <br /> ,yam (For Non-Transferable, Revocable, 5uspendable) <br /> SEPPLRA'AWKELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ,)t',lAQUiN LOCAL I <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the wor4-he-'I (@TdKcD4aT-iICa;plication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address p (.� TOti/ City/Town G4,�'� <br /> Owner's Name d] Phone <br /> Address �ec City _ L�SGifi <br /> Contractor's Name c s .tJ License0 / Business PhoneyOe�v��U7 <br /> Contractor's Address Emergency Phone cJ ! <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 ❑ PUMP INSTALLATION ❑ PUMP REPAIRJU <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field `Cesspool/Seepage Pit'-- <br /> Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <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 <br /> PUMP REPAIR: State Work Done ),LIA <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -� <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 0 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will call for a Grout Insp 'on pr' to grouting and a final inspec ' <br /> Signed X Title: Date: 3 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI 4 <br /> Application Accepted By Date a3� <br /> Additional Comments. I j <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By %1 f? Date Inspection B Date/,o--a'-2- <br /> Fee <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 14 Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> O' � S <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.Box 2009 STOCKTON,CA 95201 <br /> r'r� <br />