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Applications Will Be Processed When Submitted Properly Completed. t ems n e ppWau > <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspe } C ter' &WELL <br /> ENVIRONMENTAL HEALTH PE IT J rt <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , L <br /> fit 7Tb <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in�lAt..Ftt�Y� w�okt�h r� ed.This application is <br /> made in compliance w h San Joaqu'+ Count Ordinance Ng 1862 and the rules and regulations of tAB'Sa Joaquin Loca�H�eanit`h Dis <br /> Exact Site Address 17 City/Town <br /> Owner's Name Q d Phone <br /> Address City e.nC-V) 0.v>ti <br /> Contractor's Name Q n .. License# ��U Business Phone �'�2- 2 <br /> Q. <br /> Contractor's Address 4 done-- C Emergency h ne 4b,2" E4 2 <br /> LV <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTI N❑ �I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ -- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pik 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 /> X 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 2LLciape Seal Installed By: <br /> PUMP INSTALLATION: Contractor CAN C) n <br /> Type of Pump V`- ( H.P. <br /> PUMP REPLACEMENT: f��c tate Work Done <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. <br /> Homeowner 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I wit a Grout Inspectio r to gr ing a final inspection. <br /> Signed X ^-- Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I d — -8� <br /> Application Accepted 8 Date <br /> Additional Comments: <br /> Phase II Grout Inspection II al Inspection <br /> Inspection By Date Inspection B Date �L <br /> Fee IS Due: 11 ANNUALLY PER UNIT © PER SITE ❑ EACH ❑ January 1 & eived 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 ��� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />