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Applications Will Be Processed When Submitted Properly Completed. Be Suri TO�Sil i�*6Pj plcanon. r> <br /> FOR OFFICE USE: APPLICATION 0 � , V <br /> (For Non-Transferable, Revocable, Suspendable)�1 <br /> "A'- <br /> � / L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAi 1 ,.IOAQ r;N LOCAL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installtheH&A.bqrW qtft-Ftjsapplication is <br /> made in compliance t San J aquifl6rWZ141 <br /> mOrdinance N 1862 and the rules and regulations of the Sa Joaq In Local Health District. <br /> � 1 U; n city/Town �1 n �iY1 <br /> Exact Site Address �—,�, /�-� <br /> f <br /> Owner's Nam t Phone ` <br /> Address City <br /> Contractor's Name License# s' es Pho e <br /> Contractor's Address Jy 11117 31 Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �fl <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ TVrtiti <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 /> ❑ 1 STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L�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: ate Work Done PJ - t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> 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 followinC'J 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 ubject to workman's compensation laws of California." <br /> I c II for a In tion pri o grout' and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accept By <br /> Additional Comme ts: <br /> Phase 11 Grout Inspection11 inal inspection <br /> Inspection By Date Inspection By A1, afe 1Date SJ 7 D <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju$y 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> EEE [ S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 �- <br /> Received by Date Receipt No. Permit No, Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />