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Applications Will Be Processed When Submitted Properly Completed. Be Sur a Applicatia;t- <br /> FOR OFFICE USE: APPLICATION <br /> -- $ (For Non-Translerable,,Revacahle;Suspendable) QAP&�v If« oG�' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Q 41 C � � , ;�� . P`'' ,,f = <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work ln'described.Th'is application is <br /> �. / „ de <br /> made in compliance with San Jo uin Count rdinance No. 1862 Arid the rules and regulations,of the San Joaquin Local'Healtr IsIr ct. <br /> Exact Site Address'//661 •City, Town " 4"J PG <br /> Owner' 'Name P.h"one'- *.,sezM_15 61 15 <br /> - <br /> Address <br /> Contractor's Name License#, 1 IS <br /> Business Phone <br /> Contractor's Address gency Phone {sry=�:'• *.:*• i <br /> Is Certificate of Workman's Compensation Insurance on File dith SJ LH D? Yes No <br /> TYPE OF WORK (CHECK}:-"—NEW WELL - DEEPEN ❑ - RECONDITION❑ DESTRUGTiON❑ <br /> WELL CHLORINATION _-WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: 'Septic Tank' Se`er Lines Pit Privy k <br /> Sewage Disposal Field f" Cesspool/Seepage Pit Other h, <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL } t <br /> INDUSTRIAL ❑,CABLE TOOL,,, Dla. of Well-Excavation <br /> I <br /> ❑ INDUS -,. w. ' <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED ' Dia. of Well Casing 1 <br /> 0 DOMESTIC/PUBLIC'' ❑ DRIVEN * { Gauge of Casing <br /> ❑.IRRIGATION GRAVEL PACK Depth of Grout Seal " rit, <br /> _ <br /> ❑ CATHODIC PROTECTION ROTARY I Type of Grout <br /> 0 DISPOSAL; ❑ OTHER Other Information 777Vr' <br /> ❑ GEOPHYSICAL _? .v Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump _ - H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well:Diameter Approximate Depth <br /> Describe Material and Procedure, <br /> a <br /> I hereby'certifythat-1'•have prepared this"appli"cation and that the work will be done in accordance with San Joaquin County G <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 workJor 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 /> permit is issued,-I shall employ persons subject to workman's compensation-laws of California." <br /> I wil call for a Grout Ins ction prior-to grouting and a final inspection. <br /> r <br /> Signed X Title: Ei Date: © r <br /> (Dri- Plot Plan on Rev se Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted"By oQa ,./ V.��s� a+-��-^ate` Date T% <br /> Additional Comments: <br /> h I out flnspectipn R^ Phase ill Final Inspection - <br /> Inspection By '� Date�� <br /> Inspection 8y -/'y� Date y <br /> Fee Is Due: ❑'-ANNUALLY---"'❑�PER UNIT-_ ❑ PER SITE ❑ EACH l ❑-January 1 &Received By January 31 ❑ July-1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> - --BASE EXPLANATION, AMOUNT DUE CHECKED <br /> i DATE - DATE ;REMITTED AMOUNT <br /> - r <br /> FEE. <br /> LE-55 r i <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER y . <br /> OTHERr' <br /> i - <br /> Received by ate _. 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 <br />