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rrII�euUns will BeProcessedWhen Submitted Properly Completed. Be Sure To Si n The Application. <br /> FOR,OPFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) i •� <br /> ENVIRONMENTAL HEALTH1 ELL <br /> (COMPLETE IN TRIPLICATE) PERMIT <br /> �35'r - ,moo �D_WATER QUALITY <br /> made <br /> enmpliahereby made tothe SanJoaquinLocalHealthDistrictforapermi#to construct and/or install tlhework herein described.This application is <br /> made in compliance yvith San Joa _um County Ordinan �,v r? ` <br /> Exact Site Address ! r �e,N°' 1862 and a rules and regulations of the Saa.Joaquin Local Health District. <br /> a <br /> �'� �°�• f �" � 'C s City/Town <br /> Owner's Name g } C'JI'i tT [ t'fry° F ✓rte ' _ . <br /> Address t Phone <br /> Contractor's Name ,t , City <br /> f. r, y ! License# <br /> Contractor's Address , [ Basin s Phone <br /> Is Certificate of Workman's Compensation Insurance on Fife With SJLHD?�efgYesy Phone <br /> �ne,-F <br /> TYPE OF WORK (CHECK): NEW WELL Q-�'`�.f No <br /> WELL Ci ILORINATIQN ❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ INSTALLATION ❑ <br /> REPLACEMENT❑ PUMP, � PUMP REPAIR 11 <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field a <br /> Cesspool/Seepage Pit ^ <br /> Property Line Private Domestic Well <br /> Other- <br /> INTENDED USE Public Domestic Well <br /> © INDUSTRIALTYPE OF WELL /y)� <br /> ®'"CABLE TOOL <br /> ❑ Dia. of Well Casi <br /> OMESTIC/PRIVATE Dia. of Well Excavation `2 i <br /> DRILLED ng <br /> , <br /> ElDOMESTIC/PUBLfC <br /> ❑ IRRIGATION ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK <br /> ❑ CATHODIC PROTECTION El ROTARY <br /> Depth of Grout Seal <br /> ❑ DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Surface Seal Installed By: <br />- Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ElState Work Done H.P. <br /> PUMP REPAIR: : ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 of the work for which this permit <br /> is issued, I 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 for which this <br /> permit is issued, I shall emplo��yipersons subject to workman's compensation laws of California.,' <br /> I wilWali for a Gr 1 t InsTclion prior to!grouting and a final inspet:tion. <br /> ��. <br /> g tr <br /> Si ned X r Title: Dat <br /> Draw Plot Plan on Reverse Sided <br /> .,FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> f, <br /> �PpZsl�ll Grout I s ection <br /> P r Phase III Final Inspection <br /> Inspection By Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UN) ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUECHECKED <br /> DATE`.' DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LO <br /> Received by Cate-- Receipt No. Permit No.. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />