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Applications Will Be Processed When S bm'tied Properly Completed. B I elfo gnTheApplication!3 t I <br /> � �J <br /> FOR OFFICE USE: _ ' APPLICATION1187 <br /> S `- <br /> (For Non-Tral iliwfj n Revocable;Suspendable) JUN 414&'WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE <br /> �� �� <br /> (COMPLETE IN TRIPLICATE) �3tlMg3 S: G�{e rS,.r,4,-WATER QUALITY 14LTH DISTRICT <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 Comity Ordinance No. 1862 and the rules and"egulations of the San Joaquin Local Health ist is <br /> Exact Site,Address �E V-044- /Q.'j W10-11-7 04 - 8/-�4/� City/Town 7 /N,-,4v = ! � <br /> Owner's Name .,-. �Sr4 13 Phone' X53 &O-0 <br /> Address D_ St3 9 n City <br /> Contractor's Name _ License#o7f�B33.Z a laBusiness Phone a71-3 <br /> Contractor's Address /7-1J/ S Emergency Phone :4 S -- a <br /> } <br /> is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes `_ No <br /> TYPE OF WORK (CHECK): - NEW WELL DEEPEN ❑ -RECONDITION❑ DESTRUCTI N❑ pC <br /> WELL CHLORINATION E] WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 Welt Excavation 1.2.r <br /> ❑ DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing v2Ir <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �� <br /> �❑ IRRIGATION 11AVEL PACK Depth of Grout Seal <br /> Lte CATHODIC PROTECTION 2 ROTARY Type of Grout Ca�,ta,+ G:4ers <br /> ❑ DISPOSAL ❑ OTHER Other Information W <br /> ❑ GEOPHYSICAL - . Surface Seal I sled By: <br /> PUMP INSTALLATION., Contractor (® <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 'k`. Well Diameter s — Avoroximate Depth. <br /> Material and Procedlure <br /> I hereby certify that I have prepared this application and that-a a 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 t ' <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 w!ff all 17 <br /> a Gra s ction prior to grouting a a final inspectio / <br /> Signed X C�"'K /6°2 Title:. ; Date: b �l7 <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase If Grout Inspectionhie IIIinal_Inspection ` 111 <br /> Inspection By Date --- , Inspection By �� Date 4" <br /> Fee is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT + <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEEtit <br /> L/S <br /> LESS T <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER " <br /> OTHER _f <br /> I <br /> Received by Date .Receipt No. Permit No. Issuance Date { Mailed I Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITtSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ^vim <br />