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Application's WIII iBe Processed When Submitted Prdperly Completed. Be Sure To Sign The Application. <br /> OR OFFICE USE: f APPLICATI,N <br /> (For Non-Transferable;_Revoc#e,Suspendable) <br /> PLtMP• HELL <br /> ENVIRONMENTAL HEALTH PERMIT )e-LA), Q �J_��rcxcx h <br /> (COMPLETE IN TRIPLICATE) WATER QU¢LIT'T. <br /> Application is hereby made to the an Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance withS n oaquin County Or finance o 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �F. City/Town <br /> iF <br /> Owner's Name �� �' i' Phone. <br /> Address ,Bo r �` - _, _ City -41,o Ic?/- <br /> Contractor's Name o- " Gj+ ��� nse# 1GP��3 Business Phone —T-6 — 116-7 <br /> Contractor's Address v?a20 COX, Sp4-1AA ' Emergency.Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): N 11 EW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ) <br /> I WELL CHLORINATION ❑ IWELL ABANDONMENT.[] OTHER ❑ PUMP INSTALLATIONV+ PUMP REPAIR❑ <br /> REPLACEMENT❑ i. <br /> DISTANCE TO NEAREST: Selptic Tank Sewer Lines VG Pit Privy"JV� <br /> Sewage Disposal Field - Cess�po�I/Seepage Pit �d�� Other <br /> Property Line�_�_ fivate Domestic Well,"V�e Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL XCABLE TOOL Dia. of Well Excavation_ <br /> + - - fi <br /> DOMESTIC/PRIVATE ❑kDRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC i❑.DRIVEN Gauge.of Casing AQ 5E <br /> ❑ IRRIGATION =❑-GRAVEL•PACK s Depth of Grout Seal `J <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout'f /L404- <br /> ❑ DISPOSAL ❑ OTHER Other Information. <br /> ❑ GEOPHYSICAL / ,.Surface.SeaLJnstalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump GH.P. —T— V v <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ,. <br /> I hereby certify that 1':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 /> ! <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> P 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�jsub-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 /> x_ I w' call for a Grout�lns action prior to grouting and-a final inspection.• - - - <br /> EIEF <br /> Signed X. __ ...Title: ��— �'W1��_ -'� _ pate: <br /> x (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE r: <br /> Application Accepted By. "' r0. O Date a� <br /> r Additional Comments: iigel <br /> l ase It- 1 spectiorl, Phase 111 Final 1 pec i' <br /> ` Inspection Bylnspecti Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 y JDIy 31 <br /> = y F - �$` REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED � <br /> K jIDATE r DATE REMITTED AMOUNT <br /> 9r . . p <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Ir <br /> PENALTY JL <br /> `A ER <br /> W4 Receipt No. Permit No Issuance Date -Mailed Delivered <br /> - .OPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE P.O.Box 2009 STOCKTON,CA 95201 <br />