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Applications Will Be Processed When Submitted Properly 1 t "righ,!1'rh lication. <br /> IJ <br /> .FOR OFFICE USE: APPLICATI <br /> (For Non-Transferable, Revoca I , uspendablle) <br /> ENVIRONMENTAL HEALTH PErW4 23 1981 Punnl'&WELL <br /> WATER QUALITY N U)"'AL <br /> (COMPLETE IN TRIPLICATE (1 [ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to constr�dl�jl'tx}sfi tvtiereln described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reg of the ani Joaquin Local Health District. <br /> Exact Site Address [� 4 City/Townfpc� <br /> Owner's Name 1h RP <br /> Phone /O J—S�� <br /> Address City ;7—A&ztir I <br /> Contractor's Name L4-"—, License#/14�_ 3 Business Phone <br /> Contractor's Addressp �• f3,�—f g 7 _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 0� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECON�D/I��N❑ DESTRUCTION 13r <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER L3 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 <br /> INTENDED USE TYPE OF WELL <br /> 0*frDUSTRIAL 11CABLE TOOL Dia. of Well Excavation M <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done v� <br /> PUMP REPAIR: State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter proximate Depth 96 <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 /> 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 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 —1 )9)• �.K�ri J Title: 12�A,� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i Q <br /> Application Accepted By 02 0 u Date�3� <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha e I Final Inspection <br /> Inspection By Date Inspection By � ate P_ V--� rl <br /> Fee Is Due: ❑ ANNUAL.LY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 r uly 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE c� S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER cc <br /> T: <br /> Received by - Date Receipt No. Permit No. I Isuance Dbte I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />