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Applications Will Be Procegsed When Submitted Properly Completed. BerulrIlAtAtohj�pjVcaltA. �J <br /> FOR OF.Fi^cE USEAPPLICATION J <br /> : �{ C <br /> _ ry (For Non-Transferable, Revocable,Suspends S EP 2 2 1�8 P&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ,,��� U,M <br /> WATER QUALITY $AN JOAQ <br /> OCAL <br /> (COMPLETE IN TRIPLICATE) W P{dSTRICT <br /> Application ish@rebymade tothe San Joaquin Local Health Districtforapermit-to construct and/or install t a escrlbed.Thisapplicationis <br /> made in compliance wSan Joaquin Cu y Ordin No. 186 and the .ul and regulations of the San J uin Lo' I Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License usiness Phone <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workan's C�pensatio Insurance on File With SJLHD? Yes i t No <br /> m - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLOR NON ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMEN'T � �.. <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 <br /> 'INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL - Dia. of Well Excavation <br /> ,. DOMESTIC/PRIVATE . _ ❑ DRILLED Dia. of Well Casing <br /> ` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> l 11 ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION <br /> I` ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r-Y - <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 <br /> Describe Material and Procedure <br /> c 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ! will ca! r Grout Inspecti r" io grouti and a final inspection. <br /> ;•- Signed X Title: Date: <br /> - {Draw Plot Plan on Re erre Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 11, ,_, .�.� <br /> Application Accepted By Date <br /> Additional Comments: r� <br /> se II Grout Inspection eh I `ction <br /> Inspection By Date Inspection B j e <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT PER SITE El EACH ❑ January 1 8 Received By January 31 [3 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> W FEE <br /> �qb� <br /> LESS <br /> PRORATION- - <br /> _' PLUS <br /> PENALTY <br /> OTHER <br /> g OTHER 4 <br /> Q� <br /> cr— <br /> #` Received by s Dated Receipt No �.�- Permit No, r.r, ssuance ate Mailed Delivered <br /> ,'"' 1601 E.HAZELTON AVE.,P.O.Box 2009"x`STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:"`.:ENVIRONMENTAL HEALTH PERMITIS - <br />