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Applications Will"Ba-Processed When Submitted Properly Completed. aa iT.+o ,in,Th is tion. - <br /> rM <br /> FOR OFFICE USE: APPLICATION L L <br /> t ;5& -' y, (For Non-Transferable, Revocable, Suspen <br />{ ENVIRONMENTAL HEALTH PERMIT <br /> DEC 2 2 <br /> WATER <br /> (COMPLETE IN TRIPLICATE) Q UALITY S r <br /> k Application is hereby made to the San Joaqu-inLocal Health District for apermit toconstruct and/or inst EPLwp �ri� .This application i's <br /> f made in compliance with San Joaquin County Ordinanc No. 1852 and the rules and regulations of the San Joaquin Local alth District. <br /> 1 Exact Site Address 't 4City/Townes - - <br /> Owner's NameCeV40,4 0 _ Phone <br /> Addresses S. L0 P City w <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION E] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 9 <br /> t REPLACEMENT❑ _ r <br /> DISTANCE TO NEAREST Septic Tank Sewer Lines Pit Privy <br /> Sewage-Disposal'Field Cesspool/SeepagOther <br /> e <br /> i 8"Property Line Private Domestic Well .Public Domestic Well <br /> INTENDED USE TYPE OF.WELL <br /> 6I OUSTRIAL ❑ 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11.OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor <br /> ti Type of Pump H.P.X <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth y -- <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 <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 <br /> III Grout Inspection prior to grouting and a final inspection. <br /> Signed X yeJt Title: Dale: f <br /> , _(:Draw_P.Iot-P.Ian-on-Reverse Side) —;: ' 77 - - - -r <br /> FOR DEPARTMENT USE ONLY fi <br /> I PHASE I -� _ Q ' <br /> Application Accepted By YA Date8� <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase NI Final Inspection j,_J� fl— <br /> Inspection <br /> Z <br /> Inspection By Date Inspection By Date �!''f <br /> S <br /> 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 /> yx BASE EXPLANATION DATE - .DATE -REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �S INS <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER ' <br /> t� 9'�3 � <br /> Received by - Date i Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RE-ruAN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />