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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATIONOGS— qO 37 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> `F ria":n1 CifP_a EUOP&WELL <br /> c.�ENVI ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATft�s- 77V A QUALITY � A� D � Q���� <br /> Application is hereby mad an oaq oca aXdWATER <br /> trictforapermittoconstructanc�/ormstaknw_'__14ff d.Thisapplicationis <br /> made in compliance°with San Joaquin County Ordinanc No. 1862 and the rules and regulations oftn Ith District. <br /> Exact Site Address �/� City/Tow <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name License# Business Phone %j� ---e:g <br /> Contractor's Address ,Emergency Phone r <br /> Is Certificate of Workman's Compensation Insuran on File th SJLHD? Yes �..� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 4 AV <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy G <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ,,, TT E OF WELL i/ r <br /> ❑ ]N�JSTRIAL Ir�CABLE TOOL Dia. of Well Excavation ¢ + <br /> 09/DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 14911 a, <br /> r <br /> ❑ DOMESTIC/PUBLIC C1 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4u " <br /> ❑ DISPOSAL ❑ OTHER Other Information - R ' a <br /> ❑ GEOPHYSICAL � � � - ,`t - SurfaaqSeal Installed By: � <br /> PUMP INSTALLATION: Contractor Is- <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: :` ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameterfrr Approximate Depth � c <br /> - <br /> Describe Material and Procedure ?g' <br /> 1 hereby certify that I have prepaied 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. r ; <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." i <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 empl y persons subject to workman's compensation laws of California." <br /> I will c I for a Grout Inspe Ion rior to grouting and a final inspect' n.- <br /> Ij <br /> - <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y <br /> Application Accepted By- <br /> 11-1Date <br /> Additional Comments: <br /> e II Grout Inspection ��_- � hose IkalInspection <br /> Inspection By Date �a Inspection ByDate l l Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re ed By July 31 ' <br /> REMIT N <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Q Q D� 4 <br /> LESS CC!! CJ <br /> PRORATION y <br /> PLUS - <br /> f <br /> PENALTY II <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuancd 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 />