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TheApplicauon.ti _'Scessed When Submitted Properly Completed. BeSureToSign <br /> r. APPLICATION <br /> FOR OFFICE USE:' � .� <br /> (For Nan-Transferable, Revocable, Suspendable) fj� PU P&WELL 1 <br /> ENVIRONMENTAL HEALTH PERMIT G Z r <br /> (COMPLETE IN TRIPLICATE) ! WATER QUALITY <br /> Application is hereby made to the Sari Joaquin Local Health Districtfora permitto construct and/or installtheworkhereindescribed.Thisapplic do Is w <br /> made incompliance with San Joaquin County Ordinance No. 1862 and the rues and regulations of the San Joaquin Local Health District. <br /> Exact Site Address '?11F� o 9 City/Town STILI <br /> I . Phone <br /> Owner's Name <br /> Z bO <br /> Address ?� b City <br /> Contractor's Name _ / _ License# J?()140 Business Phone <br /> Contractor's Address '� i'� ( - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, No j <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION 13 WELL ABANDONMENT C3 OTHER 11 PUMP INSTALLATION ❑ PUMP REPAi a� <br /> k REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1 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 13DRILLED Dia. of Well Casing <br /> 11 T]OMESTIC/PUBLIC 1 11DRIVEN 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 /> H.P. <br /> 117 Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: _ <br /> ❑ State Work Done Ir <br /> t DESTRUCTION OF WELL: Weli 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 /> k Home owner 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 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 trkman's compensation laws of California." <br /> cal or a Grout Inspecti for to routs and a final inspect' <br /> t <br /> Signed X Title: Date:7z <br /> y '� <br /> �-, (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT E ONLY <br /> PHASEI <br /> Application Accepted By Date �~ <br /> Additional Comments: <br /> Phase 11 Grout InspectionP ase III Final In ection <br /> Inspection By Date <br /> Inspection By-! Date <br /> Fee Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITd By u1y 31 �W- .f <br /> BASE EXPLANATION BILLING REMITTANCE TT AMOUNT DUE CHECKED <br /> n TE DATE REMlTT D AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> C PENALTY <br /> OTHER f <br /> OTHER <br /> — pate �Receipt�No. Permit No; Issuance Date Mailed, rr7elivered.` <br /> { + Received_hy ti ! <br /> R <br /> i nooi IraNT-pETGRWALL CDPIES'TO NY"^�NENTAL HEALTH PER�MITISERYICES I'll 1601 E.HAZELTON AVE.,P.O.Box 20119 - �TOCRTON,CA 45201_ a <br /> - ��� <br />