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AppiicationsWill Be Processed When Submitted Properly Completed. Be Sure?R19iIEThJp)QIc�n.� , <br /> FOR OFFICE USE: g�A <br /> �i APPLICATION }t�� ^fQ <br /> (For Non-Transferable, Revocable, Suspenda 1�1U1f11P&WELL <br /> ENVIRONMENTAL HEALTH PERMI 0C1._� <br /> II WATER QUALITY ISIS `'aC[L <br /> (COMPLETE IN TRIPLICATE) 0 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install ltp$il ro.. n>k&1-1-41PThis application is V ' <br /> made in compliance with San Joaquin County Ordinance No.1862 an th rules and regulations of the S in Donal Health District. <br /> Exact Site AddressAt I'� City/Town r <br /> Phone n ®I <br /> Owner's Name � � r M <br /> Address a City <br /> Contractor's Name License#/S�J Business Phone_ <br /> Contractor's Addres, mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL 0-- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 13OTHER 1:1PUMP INSTALLATION ❑ PUMP REPAIR❑ E <br /> REPLACEMENT[] it ' <br /> DISTANCE TO NEAREST: Septic Tank v n Sewer Lines Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br />' d <br /> Property Line Private Domestic Well Public Domestic Well 1 <br /> j. INTENDED USE ,i TYPE OF WELL <br /> ❑ INDUSTRIAL !; CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE !: ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ;j ❑ DRIVEN Gauge of Casing <br /> �IRRIGATION j' f <br /> ❑ GRAVEL PACK Depth of Grout Seal �. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL l� ❑ OTHER Other Information <br />` ❑ GEOPHYSICAL Surface Seal Installed ByT 1 1 <br /> PUMP INSTALLATION: Contractor 7 <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: �j-`� <br /> El State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> f II <br /> P 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> kis 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 call for a Grout Inspection prior to grouting and a final inspection. _ <br /> Signed _ Title: Date-�� G <br /> li (Draw Plot Plan on Reverse Side) <br /> a <br /> k; li ..,,FOR DEPARTMENT USE ONLY <br /> PHASE I l <br /> Application Accepted By. ° Date <br /> Additional Comments:���go <br /> Phase II Grout Inspection i Phase 111 Final Inspection <br /> Inspection By Date Inspection B Date a�—P9 T? <br /> Fee Is Due: ❑ ANNUALLY II ❑ PER UNIT ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> .I, BILLING REMITTANCE $ <br /> BASE' EXPLANATION REMITTED AMOUNT DUE CHECKED <br /> F DATE DATE AMOUNT <br /> ` <br /> FEE y3' - q3 <br /> LESS <br /> PRORATION <br /> PLUS n <br /> PENALTY <br /> OTHER <br /> OTHER :I <br /> r i <br /> toll <br /> Received by e Receipt No. ermif o. Iss ante ate Mailed Delivered <br /> Dat <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />