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. � Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. " <br /> i!OR,QFVfCE USE: APPLICATION <br /> a++t Ko (For Non-Transferable, Revocable, Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT. WEL[ <br /> - �! WATER <br /> (COMPLETE IN TRIPLICATE) ;i QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules andregulations of the San Joaquin Local Health District. - <br /> Exact Site Address GC.l yam._ Z &&City/Town 460MO,00 <br /> (� y <br /> Owner's Name Phone 7 <br /> Address _ G,. d4z&952e � City AWMS;sPVIe4n J <br /> Contractor's Name License#-15 Business Phone <br /> Contractor's Address Emergency Phone <br /> t. Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes X No f <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION❑ DESTRUCTION_❑ <br /> WELL CHLORINATION ❑ , WELL ABANDONMENT ❑ OTHER ❑ PUM—P _I�N_STALL-ATION� PUMP REPAIR❑ <br /> REPLACEMENT❑ t` <br /> DISTANCE TO NEAREST: Septic Tank I foo Sewer Lines ;?6�7 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ----�'' <br /> *, <br /> Property Linenvate Domestic Well Public Domestic Well <br /> INTENDED USE �F WELL .00 <br /> ❑ INDUSTRIAL X CABLE TOOL Dia. of Well Excavation �� �52 <br /> )KOOMESTIC/PRIVATE `❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �� I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout : <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor Z2,L&LI' <br /> I' Type of Pump P. <br /> PUMP REPLACEMENT: " ❑ State Work Done <br /> E PUMP REPAIR: ! ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .. d <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 /> . <br /> Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of thework for which this permit <br /> f 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 /> permit is issued, I shall employ persons subject to workman's compensation laws California." <br /> I will all for a Grout Ins eciion p for to grouting and a sinal inspection. - <br /> ! Signed X Title: Dater <br /> r _(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> F• <br /> Application Accepted By I! / Date <br /> Additional Comments: `I �i g- Y 1rLI <br /> kittG�U <br /> II Grout Inspection' IILFina Inspection <br /> Inspection ByJJ' Date Inspection By Date (AL <br /> y u <br /> �y Fee IS Due: ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> L AMOUNT <br /> i FEE 3"� <br /> LESS <br /> PRORATION I __ <br /> PLUS <br /> PENALTY <br /> f' <br /> OTHER <br /> !- OTHER „'"^, ..^"`- <br /> 6 <br /> Receivedbt� +,,,,. Date - Receipt No. Permit No. resuahce orate Mailed DeEivered <br /> APPLICANT—RETURN ALL COPIES TO:.._ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.`Bo■2009• STOCKTON,CA 95201 <br />