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Pomo'� 'Applications"Will-Be Processed When Submitted Properly Completed. Be sure Iosign Ine ppuvauun. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pupftp&WELL <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> i <br /> (COMPLETE IN TRIPLICATE) I X 0 ►k��r("��+ WATER QUALITYcon <br /> Application is hereby made to the San Joaquin Local Healt District for a permit to construct and/or install the work herein described.This application is <br /> f pP <br /> made in compliance wit a Joaquin Coulytt��r i ante No. 1 a d the rules and regulations <br /> f the San Joaquin Local Health District. <br /> !9 47 (�f/ till Cit /Town i <br /> r Exact Site Address <br /> s <br /> Phone <br /> Owner's Name D <br /> �..�.. City ��`r ��t'� <br /> Address <br /> Contractor's Name . �' License#/.- Business Phone <br /> 4 Contractor's Address �" C Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> t Q <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION 11PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL e' <br /> REINDUSTRIAL CABLE TOOLDia. of Well ExcavationDMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing { <br /> ❑ DRIVEN , t <br /> ❑ DOMESTIC/PUBLIC Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> � <br /> 13 DISPOSAL 1:1 OTHER Other Information 27 -� . <br /> ❑ GEOPHYSICAL Ul cc Seal Installed By: <br /> r PUMP INSTALLATION: a Contractor 1} <br /> k Type of Pump H.P. f <br /> [1 State Work Done.. <br /> PUMP REPLACEMENT: IR <br /> PUMP REPAIR: ❑ State Work Done ,4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 fork 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 /> 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 /> iI will call for a Grout Inspectionpriogo grouting and a final inspection. <br /> Title: f Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> P <br /> PHASE I0 MJA�) 01Q, �"6-�� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase Il Grout �petjj1 ase Itl In ciion b} <br /> Inspection By <br /> Date Inspection By f <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31� ly 1 ReceiveRdEMIT By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED if AMOUNT <br /> I'- FEE <br /> LESS � F <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER !1 <br /> OTHER <br /> /6 � r <br /> Received by <br /> Date Receipt No. - Permit No. - Issuance Date +`Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _1601 E.HAZELTON'AYE.,P. Box 2009. S70CKTON��CA 91 <br /> i <br />