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;'Applications WillBe Processed When Submitted ProperEy Completed. Be Sure gF�y71� 41ictio{ <br /> .,FOR OFFICE USE x APPLICATION } 7 <br /> (For Non T.ransferable,'Revocable, Suspendable) P P <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t SAN }Or"":Q�1+ . <br /> Application is hereby made tothe San Joaquin Local Health District fora permit toconstruct and/or,installthe wort�ligAifl is§c .Thlsapplication is <br /> made in compliance with San.Joaquin County.Ordinance No. 1862 and the rules and regulations of the San J.oa uin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Ju.S Phone <br /> 49 <br /> Address ¢ , . s• > , ,- City /10 ! <br /> Contractor's Name License# ` Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes , No <br /> TYPE OF WORK (CHECK): ,NEW WELL❑ DEEPEN"❑ RECONDITION❑ DESTRUCTION❑ v�AVI <br /> WELL CHLORINATION ❑ 4 WELL ABANDONMENT OTHER 13PUMP INSTALLATION❑- PUMP REPAIR <br /> REPLACEMENT❑ /,I !� <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 /> F INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL E]-CABLE TOOL---—.t, �, ;-_Dia. of Well Excavation - <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ! <br /> I ❑ 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 Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ZOH Approximate Depth <br /> Describe Material and Procedure C r <br /> k5&_ Ad CM'AA94Aa <br /> $r� i <br /> I hereby certify that I have prepared this application and that the work will b doe in accordance with San ,, n 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I will call for a Grout Inspec on prior to routing and a final inspectio <br /> Signed X _.. Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE_ONLY <br /> PHASE I <br /> �k�.Ri�.�sa \1 - ~ <br /> Application Accepted By - - -' - Dale <br /> Additional Comments: _ <br /> Phase II Grout Inspection ' P e NI Final Inspection /. <br /> Inspection By��Q,�.–TDate- Inspection By r 'Date– t y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &ReceiJed'By January 31 ❑ July 1 &Received By July 31 <br /> ' REMIT <br /> - BASE EXPLANATION BILLING REMITTANCE - - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED, AMOUNT <br /> FEE <br /> LESS r. _ <br /> PRORATION ,l <br /> PLUS r I1 <br /> PENALTY J <br /> OTHER <br /> i. <br /> OTHER <br /> i <br /> 713' <br /> Received by Date - -Receipt No. Permit.No Issuance Date; Mailed Delivered'-,.- -. <br /> APPLICANT—RETURN ALL COPFES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />