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Applications Will Be Processed When Submitted Properly Completed. 81 <br /> tien5�qnLDe1.AplVicqon.MFOR7OFFICE USE: APPLICATION <br /> ti-A. (For Non-Transferable, Revocable,SuspendI MAY 21 19M &WELL <br /> ENVIRONMENTAL HEALTH PERMIT ITIH[ <br /> WATER QUALITY SAN inp,C71 'N LOCAL <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or instaIK46,TH,,Qj pp <br /> 1R1 d.This application is <br /> made in compliance with San J aquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health DistrictI <br /> Exact Site Address 30 � -� S City/Town ,�/ 11G <br /> Owner's Name _ 1 L' 1rYL5 Phone <br /> Address L F_InkwC, 0 City__. <br /> Contractor's Name _� Y, 1Z , License#43 /Ae Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes C.0-1No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ppp,,,,,, <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 V <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: W <br /> PUMP INSTALLATION: Contractor A F'I -V - <br /> C <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done d ' <br /> PUMP REPAIR: ❑ 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. b <br /> Home owner or licensed agent's signature certifies the following:1 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 subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final ins ction. V <br /> Signed X it/�-`x. Title: v� Date: / , <br /> (Draw Plot Plan on Reverse ide) <br /> FO DEPAR ENT USE ONLY <br /> PHASE I / f <br /> Application Accepted By Date L <br /> Additional Comments: <br /> Phase II Grout Inspectio Phase Ili Final In ection <br /> Inspection By Date Inspection By e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &.Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE T �� <br /> LESS <br /> PROBATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />