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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> "r1 0�I'`JFFICE USE: (For Nan-Tran�sPlPbie Re�vocabOlNSuspendable) f v��Pl�eq WELL <br /> :."''��4� , =" til ENVIRONMENTAL HEALTH`PERMIT <br /> (COMPLETE IN TRIPLICATE)L� �'" WATER QUALITY, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit San oaquin unty rdinance No. 1862 a e rules and regulations of the San Paquin Local Health District. <br /> Exact Site Address a2 City/Town C CP' <br /> Owner's Name Phone <br /> ' Address +� 'City <br /> Contractor's Name !� �- a? License# i��/aL- Business Phone <br /> m !, Emergency Phone -3G <br /> Contractors Address <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUGTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 11 PUMP INSTALLATION�, PUMP REPAIR❑ .r <br /> REPLACEMENT 11 V; a, <br /> DISTANCE TO NEAREST: Septic Tank &0�� Sewer Lines / 6 h� = Pit Priv <br /> r+y 1 Y <br /> 'Sewage Disposal Field /1/6itJ �' . Cesspool/Seepage Pit G"It/ - Other <br /> Property Line /-Private Domestic WeII,00d Public Domestic Well — <br /> INTENDED USE TYPE OF WELL <br /> it �----- <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> .�DOMESTIC/PRIVATE ❑ DRILLED ,Dia. of,Well Casing <br /> ❑ Gauge ofi Casing DRIVEN ` �. s : q - <br /> F ❑ DOMESTIC/PUBLIC � r , <br /> 11 IRRIGATION _ GRAVEL PA?CK__-,p._�,Y.,_ . .Depth.of.Grout Seal- <br /> ROTARY <br /> eal -- - -- - Q <br /> ❑. CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL - 0:OTHER "" " _Other Informatii?ng <br /> :❑GEOPHYSICAL Surface'Seal Installed By: <br /> SPUMP INSTALLATION: Contractor v <br /> - Type of Pump MCA j I H.P. i <br /> ~ PUMP REPLACEMENT: - ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work DoneT <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe.Material and PFocedure ' <br /> - a I hereby certify that I have prepared this application and that the work Will be done'in accordance with San Joaquin County C�5 <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 /> T f Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the wo jk forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ` r <br /> � I will call for a Grout Insp ction prior to grouting and a final inspection. <br /> Signed X Title: � -t"J-Y�P.i� Date <br /> (Draw Plot Plan on Reverse Side) <br /> J__ <br /> FOR DEPARTMENT USE ONLY <br /> �}•, PHASE I <br /> Application Accepted By DateLf <br /> Additional Comments: <br /> Pha II Grout Inspecti l Phase III Final Ins ecii n — <br /> ate Inspection By T���1�: Date <br /> Insp2c I <br /> ection By �-w-� + I <br /> '- Fee IS Due: ❑ ANNUALLY El UNIT ❑ PER SITE + ❑ EACH ❑ Januaryl &Received By January 31 ❑ l 1 S Received By July 31 <br /> ! REMIT <br /> BASE EXPLANATSON BILLING REMITTANCE... 'AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ,.AMOUNT <br /> FEE' <br /> LESS - <br /> PRORATION y� <br /> PLUS <br /> PENALTY <br /> j <br /> OTHER S 3 <br /> i - <br /> OTHER <br /> �x1 <br /> Received by •Date 'Receipt No. - Permit No. -+- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />