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FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health 0, rictforapermittoconstru�tand/tw4ristalIthe work herein described.This plication Is <br /> made in compliance wi h an i County dinanc N , 1862 and the r>�s�nd regulations of the San in I i 71ct. <br /> Exact Site Address 1 �}} City/Town <br /> Owner's Name Phone <br /> Address — � City <br /> Contractor's Nam Y ` License#, 7 VI Business Phone <br /> Contractor's Address , )OJ Emergency Phone ,_ <br /> Is Certificate of Work man's�Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK(CHECK): NEW:WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION0 <br /> WELL CHLORINATION El .WEtL ABANDONMENT ❑ OTHER C3PUMP INSTALLATION I-� PUMP REPAIR C1 <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 "❑ CABL,•E.TAOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE.. -❑ DRILLED .... .. Dia,.of Well Casing o� <br /> ❑ DOM TIC/PUBLIC . . ❑ DRIVEN Gauge of Casing <br /> TION ❑ GRAVEL PACK Depth.of Grout Seal - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of,Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surf a eal Installed By: _ - <br /> PUMP INSTALLAtION: Contractor <br /> Type of Limp Cj H.P. .- <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PLIMP REPAIR: ❑ State Work Done -- ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby=certify that'l have prepared this application,and4hat the work will be done in accordance with San Joaquin Counly <br /> ordinances;state laws,and rules and regulations of the San Joaquin Local Health Dislricffs e, � <br /> Home owner-or licensed agent"s signature certifies the following:<I certify that in.tj.�;e performance of the work l<or which this per relit <br /> is issued,-1 shall not-employ any person in such manner as to become subject to workmares compen satiomlaws of California" <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in•the;performance of the work for which IIH$ <br /> permit is issued. I shall employ persons subj ct:to orkman's cornpensatioaAaws of California:-' <br /> -1I all fora Gr urt Inspection prior g utin nd a final inspec' <br /> .. Signed X �� Title: Mate:W -- <br /> (Draw Plot Plan on Reverse Side) <br /> 4 <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I Date <br /> f.1.-p �+ <br /> Application Accepted By <br /> �( <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III <br /> 77Final <br /> ,,Inspectio <br /> ,Lci �� <br /> Inspection By Date Inspection By 2 - ate /-20" Z ` <br /> t <br /> Fee'ts Due: ❑ -ANNUALLY :❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © Jsf1y^1 AReceived By July 31_ « <br /> REMIT <br /> BASE EXPLANATION BILLING . REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED l� AMOUNT <br /> FEE r 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by_rn Date Receipt No. Permit No. Issuance Date 'Mailed "Delivefed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZFLTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />