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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. µ <br /> FOR OFFICE USE: APPLICATION <br /> F (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT AAP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San oaquin ounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo al ealth District. <br /> Exact Site Address (D C T` City/Town ,t <br /> Owner's Name Z lI' V e- • c`C' ( Phone <br /> Address City,.�_-� <br /> Contractor's Name License # B si ess Phone - 2 <br /> Contractor's Address Emergency Phone 6 4 - <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 /> WELL CHLORINATION ❑ 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 _J U Public Domestic Well <br /> d <br /> INTENDED USE TYPE OF WELL <br /> �lt <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> r <br /> Z,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> O' CATHODIC PROTECTION ❑ ROTARY Type of Grout f p7c 0i a( x <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _/46/177' <br /> C �f1H <br /> i <br /> Type of Pump.5'e 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 ppp, <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit j <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." I <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 compehsation laws of California." t <br /> I will call fora PLrout Inpec on prior to grouting and a sinal inspection. <br /> Signed X Title: 6&Mm eDate:a,71-117 �j/` l�_r <br /> (Draw Plot Plan on Reverse Side) I <br /> i <br /> FOR DEPARTMENT USE ONLY a <br /> PHASE ] <br /> Application Accepted ByVN' avzz <br /> �® Date'()- <br /> Additional Comments: <br /> s <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By?V' ��r.-1 Date A6AS-/k Inspection By a els-s,, Date //A/P/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKER <br /> AMOUNT } <br /> FEE <br /> LESS `a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No. Permit No. Iss nce DEhe I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />