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AppliC&t.,:: Will Be Processed When Submitted Properly Completed <br /> iI FOR;-OFFICE USE: � `^ APPLICATION <br /> (For Non-Transferable, Revocable;Suspen ) 197 <br /> ENVIRONMENTAL HEALTH PERMIT D C UMP St WELL `� f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN J®AQ UIN LOCAL <br /> � <br /> € Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinst" .lol�rHch���dRcCbed. Thisapplicationis� <br /> made in compliance with San Joaquin County Or 'nAnce No. 1862 nd.the rules and regulations of the San oaquin Local Health District. <br /> I� Exact Site Address QCity/Town y <br /> ,- <br /> ICity <br /> Owner's Name PhoneAddress <br /> Contractor's Name I t- <br /> License Business Phone,.. �,j <br /> i Contractor's Address Emergency Phone <br /> ;t <br /> Is Certificate WCompensation ompensation Insurance on File With SJLHD? Yes p _ <br /> e -� r; <br /> TYPE OF WORK {CHECK}: NEW WELL�. DEEPEN © RECONDITION LJ DESTRUCTION❑ Y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> EI REPLACEMENT❑ � <br /> �. DISTANCE TO NEAREST: Septic Tank /00 Sewer Lines Pit Privy } <br /> =Sewage•Disposal Field -'Cesspool/Seepage.Pit'= /� ..--Other <br /> E Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> hh ❑ INDUSTRIAL `Z CABLE TOOL Dia. of Well Excavation -D �f <br /> fl DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing $' <br /> �� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -4 <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑.State Work Done <br /> J: PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _- <br /> I r <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 /> i Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> i <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 /> E I will tali for a Grout I spection prior to grouting and a final inspection. <br /> `° Signed X A49nN— -.,-,.Title:'t�;). nni-0 r _— Date: +� G <br /> Plot Plan on Reverse-Side) <br /> i OR D PARTME USE ONLY r.t ' <br /> I PHASE I <br /> Application Accepted By _ Date - <br /> E Additional Comments: •:' ' <br /> Ei s Grout , ection <br /> k P f� Pha I Final In "ection <br /> Inspection By Date /V a Inspection By Date v 0 V i <br /> .� Fee IS Due: ❑ ANNUALLY ❑ PER UNIT �+7 PER SITE ❑ EACH ❑ ,January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATI N REMIT <br /> BILLfNG REMfTTANCE $ AMOUNT DUE CHECKED <br /> - - DATE DATE REMITTED AMOUNT <br /> At 0 <br /> FEE <br /> ' LESS <br /> I PRORATION <br /> PLUS <br /> ii PENALTY <br /> `I OTHER # <br /> OTHER <br /> E. <br /> 1 <br /> li <br /> -7 / <br /> Received by Date. w - Receipt No Permit No. Issuance Date Mailed Delivered <br /> .i -� APPLICANT�RETURN ALL COPIES'TOit ENVIRONMENTAL HEALTH PERMIT/SERVICES. .16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />