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Applications Will Be Processed When Submitted Properly Completed.13i Su�rII Sign t-"A <br /> APPUCAT[ONi s k,„ <br /> FOR OFFICE USE: t•r,9 11t1 �,, � 1 <br /> (For Non-Transferable, Fievocabl�, 6'YSpendable) E <br /> *� t �-�y� <br /> ENVIFk©N1VlENTA w 117A OJERMI-CG OV J � 5� <br /> COMPLETE IN TRIPLICATE) VWATER QUALITY 1.00'1 SAN 1, -op <br /> •5 <br /> A L <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstru andYorinsta�l'tl eswkeKt f erein desci� e T#jai a p i atibr rs <br /> ' s <br /> made in compliance wi San Joaquin County Ordinance No. 1$62 and the rules and reguLr <br /> tionsf t San Joaquin Local Health Distn 'jc{rf3 . <br /> Exact Site Address City/Town <br /> Owner's Name ARA ^_ � Phone <br /> Address �" rl City II <br /> Contractor's Name License#A0 .37J Business Phone r 1 <br /> Contractor's Address _ J-__�f?r _� � Emergency'Phone' <br /> Is Certificate of Workman's Compensation Insurance on File±� JLHD? Yes No <br /> TYPE OF WORK (CHECK): - NEW WELL❑ - DEEPENS RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 1 �� Ag <br /> DISTANCE TO NEAREST: Septic Tank x Sewer Lines Pit Privy Q" <br /> ,, <br /> Sewage Disp,Rsal`Fid ! !4 Cesspool/Seepage Pit Other <br /> ! 11Property L•'rine '` rPr�ivate Domes�fic Well Public Domestic Wel <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL = w ❑ CABLE TOOL Dia.-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 /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal JnsY Iled By: <br /> PUMP INSTALLATION: Contractor -'`- <br /> Type of P,ur1Rp - �'-' 1 H.P. <br /> 1 ` r <br /> PUMP REPLACEMENT: ❑ State Wo•rR.Dobe�'" <br /> l <br /> ��;' 4 } <br /> PUMP REPAIR: El State,Wor�f`c Done -`' <br /> DESTRUCTION OF WELL: �rWA Diameter * Ap Foxjmate Depth <br /> DescribeMa'terial and Procedure <br /> t A <br /> I hereby rtify that I have prepared this application and that Tfte work will be dq+a mr,"accordance witWSan Joaquin County i <br /> -•ordinances,.state laws, and rules and reg,lations of-the _ohe San J {uin Local Health .istrict _._.e,„„`. _ <br /> .. .. '. <br /> 'FA <br /> Homeowner or licensed agent's signatUreeertifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shallrnot employra'nypersan in such manner as to become subject tolworkman'S*,ompensation laws of California." <br /> Contract6rr's hiring'or sub-contracting signature certifies the following:"I certify thitin`the periot nahce of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation NaW dfdCalifornia.";, 3 <br /> I will call for a Grout Inspection prior to grouting and a final inspectI64.5-1/ <br /> Signed X 4 Title: 0' Date; <br /> (Draw Plot Plan on Reverse Side <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (� p <br /> _.Application-Accepted.By------t,) . �f��/\.,� _ - - ---- �. _ _ !" ':.G� O -Date <br /> Additional Comments: <br /> Pha 11 Grout Inspection ti ; se- II F' 4 <br /> Inspection By Date - - `� nsct• <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT , ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By'July 31 <br /> REMIT <br /> BASE EXPLANATION ,BILLING REMITTANCE AMOUNT DUE CHECKED— '.- <br /> DATE E REMITTED AMOUNT .�. <br /> } D <br /> FEE <br /> LESS <br /> PRORATION <br /> ­PLUS...-...J.,.__.....�.�.,�T..:__....:__.r.�—�.-.--...��.f�..—._......__.v,. - - �.-•..-..----'-"-� <br /> PENALTY <br /> OTHER . <br /> i r <br /> OTHER <br /> -Received by Date Receipt No. - Permit No. I suance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />