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Applications Will Be Processed When Submitted Properly Completed. Be Sur To-S' Appi!cation. <br /> APPLICATION ti�3 �' <br /> FOR OFFICE USE: ° I <br /> (For Non-Transferable, Revo le"Suspe datit ) M�&WELL <br /> 11 1 <br /> ENVIRONMENTAL HIEALTPERMIT <br /> ,WATER QUQ�I�Y [)�i <br /> (COMPLETE IN TRIPLICATE) y :_ - <br /> Application ishereby made tothe San Joaquin Local Health District for apermit toconstruct and/or install.th4rk' eindescribed.Thisapplicationis <br /> r. <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and eg atipns.of e�S�Y VQ,in Local Health District. , <br /> Exact Site Address / S l �✓ - �f -* ri,Cit/To n <br /> Owner's Name �- O' Phone <br /> Address 4", - City' <br /> !i' I - -� Q <br /> Contractor's Name License#1 Business Phone' <br /> Contractor's Address Emergency Phone `< <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No � , <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C3 - .PUMP REPAlR� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer 4ines lk , Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> l <br /> INTENDED USE [ TYPE OF WELL <br /> V 1:1 t7DUSTRIAL- ❑ CABLE TOOL Dia. of Well Excavation <br /> L 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:.... <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 4z,- <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 .J <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District <br /> Homeowner 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 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 inspection. <br /> Signed X - - <br /> Title: se Side Date: <br /> (Draw Plot Plan on Rever <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 7.REMITTANCE <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection li Inal Inspection Inspection By Date - ction y Date ��—Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACary 1 & cei d By January 31 ❑ July 1 8 Received By July 31 <br /> REMITBILLING $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> _ a <br /> FEE <br /> LESS <br /> PRORATION s <br /> PLUS <br /> PENALTY <br /> ! OTHER <br /> OTHER ff/ <br /> I uance ate Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Boa 2009 STOCKTON,CA 85207 <br />