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Applications Will Be Processed When Subinitted-Pri ly Completed. Be SuSign The Applicatorl ! ~ <br /> FOR OFFICE USE:` APPLICATIQN JUN <br /> � .i oft �I4I <br /> " (For Non-Transferable, Revocable, Suspendable) JUN 16 1980 <br /> WI;[. <br /> UM <br /> PP L <br /> & <br /> I ENVIRONMENTAL HEALTH PERMIT SAN J �,(' ,'fP LP W y <br /> AL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is� <br /> made in compliance with San Joaquin County Ordinance Na. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> i <br /> Exact Site Address � �.r )OV E City/Town <br /> Owner's Name ,] � Phone ' T7f <br /> Addressarro City �'-� .gyp/ ' <br /> Contractor's Name '% J' 4f 4.e 1s.) License#,;—?7Wl d Business Phone' <br /> Contractor's Address __a001-3 J� Emergency Phone el) 11,31 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4�IA No <br /> ` TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR If <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic.Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage 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: Contractor <br /> Type of Pump H.P. (� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IR 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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." —h- <br /> Contractor's hiring orsub-conlracting 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 caft1br a Grout Ins p9dio nor to grouting and a final inspi - . <br /> Signed X Title: - Date: ^-^✓ <br /> (Draw Plot Plan on Reverse Side) <br /> F DEP TMENT USE ONLY _. <br /> I PHASE I <br /> Application Accepted By �� Date <br /> Additional Comments: <br /> Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Im PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE BILLING REMITREMIT <br /> EXPLANATION TANCE .� AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS .• <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> OTHER <br /> OTHER - <br /> -? Igo 3 I - J <br /> Received by Date Receipt No. .' Permit No .. .. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,.P.O.Box 2009 .STOCKTON,CA 9 ' <br />