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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: / APPLICATIONS <br /> cO�xp.p[ /� (For Non-Transferable, Revocable, Suspendable) pU W <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is i <br /> made in compliance with San Joaquin Count Ordina c No. 1862 and the rules and regulations of the San Joaquin Local Health District" <br /> Exact Site Address City/Town <br /> Owner's Name "-Ile <br /> e <br /> " Phone <br /> Address ' <br /> City f <br /> Contractor's Name $ l tA.e License# Business Phoney – G 7 <br /> Contractor's Address Q0 ^, t't1 Emergency Phone �} <br /> Is Certificate of Workman's Compensation Insurance on File th SJLHD? Yes_X No <br />` TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �cO� <br /> Sewage Disposal Field - ._Cesspool/Seepage Pit Other O <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> Q,INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <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 f Type of Grout <br /> s <br /> ❑ DISPOSAL 11OTHE +fes' ' Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .. <br /> Type of Pump ) _. f H.P.— - <br /> PUMP REPLACEMENT: ❑ State 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 f\(1 <br /> „ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the fallowing:"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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California <br /> I will call fora Grout Inspection rior. o gr ting and a final Inspeclion.� <br /> Signed X C.-+ itle: Date: <br /> �. (Draw Plot PlanonReverse Side) yy. <br /> s _ <br /> FOR DEPARTMENT USE ONLY <br /> r Application Accepted By ' € .. Date <br /> Additional Comments: h <br /> Phase 11 Grout Inspection 7 al Inspection/ �J <br /> Inspection By Date Inspecti7&R <br /> y / 6 u <br /> Date <br /> •Fee Is Due:"❑ ANNUALLY ❑ PER UNIT El PER SITE El EACH 1:1 Ins <br /> ceived By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BILLING .. REMITTANCE $ <br /> BASE -EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE !ICS <br /> LESS 3 <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER , <br /> OTHER <br /> Received 6y Date -Receipt No.' Permit No. Isguancd Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />