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.. Applications Will Be Processed When Submitted Properly Com I� t1 r� 1uf <br /> oRglpjrh `ftpU <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, ndsM.� ( 16 1980MP&WELL <br /> kk ENVIRONMENTAL HEALTH PERMIT <br /> f (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOA UjN L;�OiCA <br /> Application is hereby madetothe San Joaquin Local Health District for apermittoconstructal� fls� �tt4ttl escribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and, e les and regulations of the San oaqul� Local Health.District. <br /> Exact Site Address 0 A% City/Town i � �v <br /> Owner's Name 1 4 1 l Phone <br /> Cy <br /> �12CityAddress � ..� <br /> Contractor's Name ' ✓ 1 License# 'P Business hone U <br /> Contractor's Address ;a r-.6 A2 e PI Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A'' No <br /> TYPE OF WORK (CHECK): NEW WELjiI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHERR � PUUM INET LLATIO L-0 40 �A 42 � PUMP REPAIR E] <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 40. Sewage Disposal Field —Cesspool/Seepage Pit Other <br /> I Property Line PrivateDomesticWell Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> R rz C__. .Z <br /> Type of Pump S H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth \ <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 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 /> 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 /> I will call ora Grout Ins �c`tion 'or to grouting and a final inspectio <br /> Signed X :Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t OR D ARTMENT USE ONLY <br /> PHASE I / C) <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By� Date &0� <br /> r <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> hhh REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I (I DATE DATE REMITTED /v/� AMOUNT <br /> FEE LfjJ IS <br /> LESS <br /> PRORATION - <br /> f PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ' (0 <br /> Received by Date Receipt No Permit No. issuarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:-. ENVIRONMENTAL HEALTH PERMIT/SERVICES 16Di E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />