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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application_ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) J <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J qui County rdin nce Nci 862 an th rules and regulations of the San Joaquin Loca Health District. <br /> O <br /> Exact Site Address �ft' City/Town R: elJ'? . <br /> Owner's Name <br /> _1`0 Phone J---V 7.7' <br /> Address _ CityL�. ` t� <br /> Contractor's Name License # 3y-` Business Phone - � 7� <br /> Contractor's Address � k� 40%4 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK {CHECK): NEW WELL W- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR Cl <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i <br /> Sewage Disposal Field '00 Cesspool/Seepage Pit. Other.___ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r I <br /> ❑ INDUSTRIAL R-CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �25_2) • _ <br /> El CATHODIC PROTECTION 11 ROTARY Type of Grout _k- �[hey _ __-- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SLYrfa a Seal Installed By: _(]Ad <br /> PUMP INSTALLATION: Contractor <br /> . Imb- --- <br /> Type of Pump .0,ff. - __ 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 <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 forwhich tlh Is 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 employ persons subject to workman's compensation laws of California." <br /> I will 11 fora Gr ut I section pria[.to grouting ami a final inspection, <br /> t. <br /> Signed X Title: _1!2-1Ie-_f �Jt a{+r—_ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha , III Final Inspection <br /> Inspection By • �fe�.L�u�---- Date ` F2 - Inspection By ( �w✓:� — Date 7 /��u <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 5 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> A <br /> AMOUNT DUE —CHECKED <br /> MOUNT <br /> FEE - {as t•'j�, I �[ <br /> LESS -_-- <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No: Permit No.� Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,C�,9�01 <br />