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T _ Applications —� n submitted Properly Completed. Be Sure To Sign The Application. j <br /> I FO OFFICE USE: ��- o� APPLICATION \\ <br /> �� ,P�(For Non-Transferable, Revocable, Suspendable) T� <br /> wit ENVIRONMENTAL HEALTH PERMIT PMP&WELL <br /> c�/-� (,#� i "� ; <br /> (COMPLETE IN TRIPLICATE) 5 WATER QUALITY - � <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is , <br /> tt made in compliance wiltSan Joaquin County'Ordinan o. 1862 and a rules and regulations of the"-0-hp,n Lo I H-e4ith District. <br /> Exact Site Address © —�/i'�1 � � eJ'� City/Ta {-(3l� <br /> i <br /> Owner's Name.r77Phone <br /> G Address '' City, <br /> Contractor's Name fce se Business PhoneL�.� <br /> i Contractor's Address Emergency Phone .4 'J� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4— No <br /> TYPE OF WORK (CHECK): NEW WELL 2��'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ' DISTANCE TO NEAREST: Septic Tank Sewer Lines u Pit Privy <br /> Sewage Disposal Field fif— Cesspool/Seepage PitAr:z n:?- t Other �--^ <br /> 4 <br /> Property Line Private Domestic Well .. Public Domestic Well --�-" <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation W <br /> O ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing g <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0-TRAVEL PACK Depth of Grout Se G <br /> ❑ CATHODIC PROTECTION EOTARY Type of Grout e" ; <br /> ❑ DISPOSAL ❑ OTHER Other Information yam' <br /> a ❑ GEOPHYSICAL - Surface Seal Installed By• G . r4P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i' 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 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 0I <br /> is issued, I shall not employ any person in such manner as to become subject forworkman'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 far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ' will call for a Grout In I prl to routing and a final inspection. 741 Si Title: 4`J Date: <br /> (Draw Plot Plan on Reverse Side) <br /> E <br /> FO DEPARTMENT USE ONLY + <br /> I PHASE t . <br /> Application`Accepted By � Ix Date �7 ' <br /> Additional Comments: <br /> Phase II Grout Inspection � Pha III Final I,n�_speIon <br /> Inspection By Date `s d"nspection:B,r � Date,( <br /> if <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT Nr PER SITE .,..❑ EACH ❑ January 1 &Received By January 31 ❑ July f&`Received By July 31 <br /> REMIT <br /> ' BASE EXPLANATI N BILLING REMITTANCE $ AMOUNT DUE CHECKED .� <br /> DATE DATE REMITTED . AMOUNT <br /> L 4'� ; <br /> 7 i <br /> FEE / I % <br /> Ll <br /> LESS <br /> PRORATION 4 <br /> PLUS - <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> r S 1 1. `7 <br /> krt <br /> F Received by ate. Receipt N '� Permit No. Issuance Date -- Mailed Delivered <br /> '" APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PER MITISERVI CES g' 1601 E.HAZELTON AVE.,P.O.Dom 2009 STOCKTON,CA 95201 --�/ <br />