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..-�.-- <br /> Prod When Submitted Properly Completed. lie Sure To Sign The Ap 1 iol.A I U I� 9 1981 <br /> / '+ <br /> FOUSE: <br /> ICATION <br /> OAPPL <br /> �o� P_ 91 'r r�- <br /> (F on-Transferable, Revocable, Suspendable) ti)w ,,; E,,,,, . ,� <br /> SAN 0AQLJ1N (9�_ L. '� HEAL N ISTR GT Aio <br /> �{E�,LTH ®iS hWIRONMENTAL HEALTH PERMIT 51*rf ��� <br /> WATER QUALITY �n� i' <br /> (COMPLETE IN TRIPLICATE) "N'Lf� <br />_-J"WIicationishereby made tothe San Joaquin Local Health District for apermit toconstZreations <br /> r install the work herein described.This application is <br /> made in compliance with San,Joaquin Count Or 'nance No. 1862-and the rules an of San Joaquin L cal Health District. <br /> Exact Site Addrass <br /> Owner's Name Phone' <br /> Address :_ City <br /> Contractor's Name License us ess Phonne <br /> Contractor's Address Emergency Phohe 19 Gam' <br /> Is Certificate of Workman's ompensatiod Insurance on File With SJLHD? Yes No M <br /> TYPE OF WORK (CHEC ): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ "�\' <br /> WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ . 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 /> TENDED USE TYPE OF WELL <br /> ❑ IN US TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 1:1 DRILLED Dia. of Well Casing j <br /> 11D MESTIC/PUBLIC C1 DRIVEN Gauge of Casing <br /> ❑ I I.GATION 11 GRAVELPACK Depth of Grout Seal <br /> El 10 <br /> PROTECTION Cl ROTARY 'Type of Grout <br /> f ❑ DISPOSAL ❑ OTHER Other Information y) <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP_INSTALLATION:' Contractor <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: ate Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure, <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San77Joaquinunty <br /> ordinances, state laws, and rules and regulations of the San Joaquin.Local Health District.Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forermit <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 /> Fcalr a Grout Ins n pr' to grou anda final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Commen "J <br /> ts: <br /> 11 rout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By�• Date <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH TI January 1 Ceived By January 31 ` ' ❑ July 1 &Received By July 31 <br /> IREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE CV� , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k 4 q f <br /> r c 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.O.Box 2009 STOCKTON,CA 95201 r <br />