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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION I'PLIMP&WELL(om�7 k0'4f� (For Non-Transferable, Revocable,Suspendable)_� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) F{ra.1-4 o ,WATER QUALITY ! <br /> Application is hereby made to the San JoaquinLocal Health Distri tforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with Sanf oaquin County Ordin nce No.. 1/8`62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 ��l�,S;r2.- �« * City/Town <br /> Or I <br /> Owner's Name Alyo f'0 Phone <br /> Address 3 G ' City <br /> Contractor's Name License# 1.3��f;�usiness Phone GY r a <br /> Contractor's Address OC% 50;� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes_._X _ No (� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 0 <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 tr4 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing - -C, <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal m <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal last led By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. G C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: W State Work Done 'J <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,1 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 /> 1 ill call for a Grout�Inssp n no ting and a final inspection. <br /> Signed X!X7itfe: per' Date: <br /> (Draw PI an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ DAM 0 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase It rout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By� //' �-- Date - <br /> Fee Is Due: 11 ANNUALLY El PER UNIT EI PER SITE ❑ EACH EI January 1 &Received By JdrV 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 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.Bor 2009 STOCKTON,CA 95201 <br /> J <br />