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Applications Will Be Processed When Submitted Properlycorib 1 d� <br /> fFOR.OFFICE USE: APPLICATION �^ j <br /> (For Non-Transferable, Revocable, SuspendazaELLi 3_iL1�;w �' S• <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 1 ,.',(11UH1 I L 1 <br /> (COMPLETE IN TRIPLICATE) I is application is <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instah�l}�9 e�C; <br /> made in compliance with tS�n J a in Count �mane N . 1862 and the rules and regulations of the8y oagwn ocal eat h District. <br /> 7 a ( &T!P a City/Town <br /> Exact Site Address � �� <br /> Phone <br /> Owner's Name City <br /> "74/8'2 56 <br /> Address Z Business Phone <br /> icense# <br /> Contractor's Name Emergency Phone _ <br /> Contractor's Address I Z G <br /> Is Certificate of Workman's Compensation In 1 It LHO? Yes <br /> No <br /> t TYPE OF WORK {CHECK): NEW WE EEPENX ECQNDITION❑ DESTRUCTION❑ L <br /> WELL CHLORINATION ❑ WELL ABANDO OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv ' <br /> E DISTANCE TO NEAREST: Septic Tank � Sewer Lines � y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11INDUSTRIAL CABLE TOOL Dia. of Well Excavation { <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE. waA I <br /> 13 DOMESTIC/PUBLIC C3DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface peal Installed y: <br /> Contractor r <br /> j PUMP INSTALLATION: <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> El State Work Done <br /> . PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter T <br /> Describe Material and Procedure <br /> C <br /> 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 forwhichthis 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 /> K permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> k I will a for a Grout Inspection prior to grouting and a final inspection. <br /> - r ] p' <br /> r <br /> Title: -61 Dale: !! <br /> Signed X <br /> (Draw Plot Plan an Reverse Side) + <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I h Date <br /> Application Accepted By <br /> Additional Comments: <br /> hale Nl I t ection <br /> Phase Il Grout Inspection <br /> Inspection 8y <br /> Date Inspection By <br /> f <br /> Fee Is Due: ANNUALLY PER UNIT ❑ PER SITE EACH ❑-January 3 &Received 8y January 31. ❑ July 1 &Received 31 <br /> REMITu y <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT <br /> FEE 4 4L 43 <br /> f <br /> t LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ln <br /> - <br /> .PermoNo. issuance Date Mailed Delivered <br /> Received by ate eceipt No. <br /> k Boa 2099 STOCRTON,CA 95203 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM <br /> ITlSERVICES 1603 E.HAZELTAVE.,ii <br />