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—.r—� A �sure io blgn 1nexpN1+*als . <br /> Applications Will Be�Processed�When Submitted Properly omp ,. <br /> l FOR ofFlcE usE: APPLICATION 9n �L 198 <br /> (For Non-Transferable, Revocable, Suspendable MP&WELL <br /> ENVIRONMENTAL HEALTH PERI�� Q ,P}' 1 tR��� <br /> WATER QUALITY HFp,LYH D <br /> (COMPLETE IN TRIPLICATE) <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described,Thisapplication ls <br /> made in co <br /> Exact Site Address with San Joaquin Cc ty Ordinance No. 1862 nd th rules and regulations of the San oaquin ocal He t istrict. <br /> City/Town <br /> �7 <br /> Phone r <br /> Owner's Name City <br /> Address )Business Pho e <br /> Contractor's Name License# <br /> " Emergency Phon <br /> Contractor's Address No y <br /> Is Certificate of Workman's Compensation surance on File With SJLHD? Yes <br /> MTYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 RECONDITION 13DESTRUCTION❑ <br /> WELL4G-HL•ORINATION ❑ WELL".ABANDONMENT 117- OTHER ❑ PUMP INSTALLATION © PUMP REPAIR❑ <br /> ! REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> r Property Line Private Domestic Well Public Domestic Well <br /> r. INTENDED USE TYPE OF WELL <br /> ❑ I USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> D9fVFEST4e/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - <br /> t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL C3 OTHER <br /> Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT: t ❑ Stat Work Done <br /> PUMP REPAIR: tate Work Done ---_ - <br /> K Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> 1 hereby certify that 1 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 i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ----------------- <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 compensatio laws of California." <br /> I will call faro n ection prior grouti and a final inspectio t <br /> le- Date: <br /> Signed X <br /> (Draw Plot Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASEI <br /> d Date D <br /> Application Accepted By <br /> Additional Comments:. <br /> r Phase II Grout Inspection P4PhdSq! III Final Inspection <br /> Inspection By <br /> Date Inspection By Date I PG TJ <br /> i <br /> E] PER SITE EACH ❑ January 1 &Received By January 31 E] July 1 &Received By uIy 31 <br /> Fee IS Due: ❑ ANNUALLY [3-PER UNIT EMIT <br /> ! BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> .BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 0 <br /> FEE <br /> I LESS <br /> PRORATION - - <br /> PLUS <br /> �. PENALTY <br /> I <br /> OTHER <br /> I <br /> OTHER, - B <br /> w ...-N I ua at� Mai$ed Delivered <br /> ` Date Receipt No er it No e f <br /> Received by - - <br /> 5 APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1607 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />