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Applications Will Be Processed When Submitted Properly Completed. Be S e e p a V <br /> FOR,OFFICE USE: KK APPLICATION / <br /> (For Non-Transferable, Revocable, Suspenda I <br /> �x ENVIRONMENTAL HEALTH PERMI JUN 2 S 1T&' ELL <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY p� tt � + <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst6awk�h �Yiest>'fl5� fihis application is <br /> made in compliance with 0aounty Ordinance No.1862 and the rules and regulations of theHEA6[ t nQ!5T19 District. <br /> Exact Site Address �' .�/.y °. . �AJE5_14,e C/ `� City/Town "1100 <br /> ��LCI d6w <br /> Owner's Name Amt ail Agr-*.61W B __ Phone .S`-�L <br /> Address el so—, S'&.4--.4W 60. City—•�S�i'J�®fix!9S3rz z <br /> Contractor's Name y � jer�. License Business Phone�+�� <br /> 6 <br /> Contractor's Address 18. Emergency Phone f /0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL,CHLORaII.NATION ❑ ` 1NELL ABANDONMENT.©. OTHER 11 PUMP INSTALLATION, PUMP REPAIR❑ <br /> 'CI <br /> "REPLACEMENTM., 7 <br /> ,.: Wiz-�v . <br /> .DISTANCE TO NEAREST: Septic Tank 40i5i Sewer Lines "!t1ij Pit Privy. <br /> Sewage Disposal Field Ces`spooi7Seepag2 Pit -`` Other <br /> Property Line Private Domestic Well 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorMM <br /> Type of Pump �Y.E1YG� H,P. �- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done B <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure } <br /> t <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will tail for a Grout In ection prior to grouting and a final inspection. <br /> Signed X - `""Title: Date: 4T <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pp <br /> Application Accepted By, Date bad. <br /> Additional Comments: C - _ <br /> Phase 11 Grout Inspection Phase III Final Inspection R <br /> Inspection By Date Inspection By Date to O""w <br /> FeeIs Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> RATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT + <br /> FEE L�S 1f <br /> !_ESS � ^ <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by J DatEii Receipt No. Permit No. Issuance Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2008.--STOCKTON,CA 95201 <br /> 1 <br />