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p Applications Will Be Processed When Submitted Properly Completi . e�4rvjo�9IgnThe IcAW. <br /> FOR R&FICE USE: APPLICATION $� <br /> (For Non-Transferable, Revocable, Sus p le) rE� 19 8 <br /> j ENVIRONMENTAL HEALTH PERMIT ` �O EP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S01 Jc B +.Mcc� CP <br /> C <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or ins work,hereindescribed.This application is <br /> made in compliance with San Joan County Ordinance No.1862 and the rules and regulations of the San Juin Local Health District. { <br /> Exact Site Address City/Town /re�ir <br /> aim <br /> Owner's Name Phone 0 <br /> { <br /> OF as s <br /> Address City <br /> Contractor's Name icense# �_ Business Phone <br /> Contractor's Address Emergency Phone <br /> i <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDON�`MENT ❑ OTHER E] PUMP INSTALLATION,91_PUMP REPAIR 13 } <br /> REPLACEMENT❑ may._ <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 /> ❑, D ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �M <br /> Lg IRRIGATION ❑ GB2sVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION � ROTARY Type of Grout �� f <br /> ❑ DISPOSAL ❑ OTHER Other Information _J <br /> ❑ GEOPHYSICAL Surface Seal Inst led By: o" t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done }I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �f <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." <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 to workman's compensation laws of California." <br /> I wilt II for a Grout In ection prior to grouting and a final inspection. <br /> t r /jam <br /> Signed X Title: - Date: _X, <br /> - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE T <br /> M <br /> Application Accepted By Date1 <br /> Additional Comments: <br /> —2 MI/ d <br /> Phase II Grout Inspection h III Fina nspection <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT E4 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION - BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> D TE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> ry <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.D.Box 2009 STOCKTON,CA 95201 - <br />