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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t <br /> FOR OFFICE USE: APPLICATION y <br /> (For Non-Transferable, Revocable, Suspendable) <br /> UMP&V17ECL <br /> ti ENVIRONMENTAL HEALTH PERMIT - <br /> r <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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> E Exact Site Address City/Town C . <br />` Owner's Name Phone F <br /> Address i City _� &; <br /> Contractor's Name L Q e3 k m Pyx License # 6l�,3 Business Phone $` 8 3 7 8 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION( PUMP REPAIR❑ �J <br /> REPLACEMENT❑ a <br /> DISTANCE TO NEAREST: Septic Tank ion" Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property_ �._.; ' <br /> P Y ..Line�t�.Private'.Domestic Well's CS,,-Public_Domestic Well � <br /> INTENDED USE TYPE OF WELL <br /> ❑1INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ..DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 iiz 4t 42, <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information (T <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> Y <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: "' ❑ State Work Done <br /> PUMP REPAIR: 4&0 ❑ State Work Done T _ <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 the work forwhich this permit <br /> is issued, I shall.n.ot employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, f shall employ persons subject to workman's compensation laws of-California." <br /> I ill call for a Gro I pection prior grouting and a final inspection. <br /> Signed XTitle: ? Date: -' <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY�- 4 <br /> PHASE <br /> Application Accepted ByDate 7 3 7r <br /> Additional Comments: <br /> Y Phase li Grout Inspection hase III Final Inspection ) <br /> Inspection By Date Inspection ByN. <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING HEMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE C/P_,F� Y3V <br /> _ 7 <br /> LESS <br /> PRORATION ez, <br /> PLUS to <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 PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />