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ApplicationsWill Be Processed When Submitted Properly Completed. Be'Sure To Sign.The Applicatipn. <br /> FOR OFFICE USE: APPLICATION <br /> f <br /> (For Non-Transferable, Revocable, Suspendable} <br /> — ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or instalR'tRe_wock herein describetl.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address . 62W—Agande—001m City/Town —StpC]LtO <br /> Owner's Name <br /> Phone 93 <br /> Address <br /> City <br /> Contractor's Name License# <br /> aux —S �'1 ?F7��� Business Phone <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 Cl DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS PUMP REPAIR El <br /> REPLACEMENTS <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines— <br /> — Pit Privy _ <br /> Sewage Disposal Field .- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL — <br /> ❑ <br /> INDUSTRIAL 11 CABLE TOOL <br /> ❑ INDUSTIC/PRIVATE ❑ Dia. of Well Excavation_ <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout <br /> 11 OTHER __ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Mnnam211 8 Water Systems Lill) <br /> C <br /> Type of Pump H.P.— — <br /> PUMP REPLACEMENT: State Work Done n>Es 7 1 0r7sri <br /> PUMP REPAIR: ❑ State Work Dane _ <br /> DESTRUCTION OF WELL: Well Diameter_ 7inc�itl —� - <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:1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: _ / Date: , j <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments:— Date <br /> Phase Il Grout Inspection <br /> Inspection By_—w-ch— <br /> w Date — _ Phase III Final Inspections_ <br /> — —. — Inspection By Z�° T Date u <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ <br /> EACH January 1 &Received By January 31 <br /> ❑ July 1 &Received By July 31 <br /> —.H _ <br /> BASE EXPLANATION T BILLING REMITTANCE $ REMIT <br /> _ DATE DATE AMOUNT DUE CHECKED <br /> FEE <br /> — — u _ REMITTED T�� �— — — c AMOUNT — <br /> ' <br /> PRO �— <br /> RpRATION � — <br /> PLUS <br /> PENALTY - <br /> OTHER � -- — — <br /> OTHER <br /> ceived bR <br /> y Date — — , <br /> eceipt No. Permit No, I suanc Date — — <br /> ReAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> 16p1 E.HAZELTON AVE.,P.O.Box 2009 STOC1(TON,CA 95201 <br />