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b fitted Properly Completed. BeSur Top ae+gw+sr�Plwalivip• t=! <br /> Applications Will Be Processed Wht n ' III f <br /> FOR OFFICE USE: APPLICATION jl�j 111J f0A I JJJI <br /> sy (For Non-Transferable, Revocable, Suspendable) DEC 1 t M WELL cu '. <br /> ENVIRONMENTAL. HEALTH PERMIT SIGNOAQUINLOCAL <br /> WATER QUALITYH � , dGu� <br /> (COMPLETE IN TRIPLICATE) si is application is <br /> Application is hereby madetotleSanJoaquin Local Health District for apermit toconstruct and/or install I <br /> made in compliance with San Joaquin County 0 finance No. 1 6�and the rules and regulations of the San Jo ealth District. <br /> � In Local <br /> City/Town , <br /> Exact Site Address—_;_31U_ + <br /> Phone <br /> Owner's Name <br /> City �1f '7– <br /> Address0VO Business Phone <br /> I Contractor's Name _ �/_(� _ License#��� <br /> Emergency Phone <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> � <br /> DEEPEN <br /> ELL <br /> TYPE OF WORK (CHECK): <br /> WELL`ABANDONMENT ❑❑ OTHER <br /> ITI P ❑P INSTALLATION O❑ PUMP REPAIR❑ 4 <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Pit Privy '• <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other � <br />+ Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i AIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ` Cl CATHODIC PROTECTION ❑ ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r/, <br /> PUMP INSTALLATION: Contractor H.P. V1J <br /> Type of Pump V-\ <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: { <br /> PUMP REPAIR: r. State Work Done <br /> I. Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> h <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 shal4 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 /> k permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> j I will c a Grout ins cti rior to routi g and a final inspection. 7 <br /> Title: Date: <br /> Signed X (Draw Plot Plan on everse Side) <br /> ' FOR PARTME USE ONLY <br /> 3 <br /> PHASE I Date ?/ <br /> Application Accepted By <br /> Additional Comments. P s II i al Inspection <br /> Phase 11 Grout Inspection Date <br /> Inspection By � �^"✓""�' Date inspection 8 <br /> r July 1 &Received 8y July 31 <br /> 1�h <br /> PER UNIT yt PER SITE ❑ EACH El January 1 eived By January 31 ❑ <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> EXPLANATION BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE DATE DATE R TED AMOUNT <br /> FEE <br /> LESS <br /> t. PRORATION <br /> PLUS <br /> PENALTY <br /> k. OTHER <br /> ( OTHER <br /> - e? 3 .7 <br /> i r 3 1 ceipt No. Permit No. Issuance Date Mailed Delivered <br /> Date Re <br /> E Received by kN 1601 E.HAZELTOAVE.,P.O.Box 2009 STOCK70N,Ca 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />