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Apprlcatrui s wrur ae erocesseu wrien auumnteu Properly Gumptlit ,9'J� �e pijc ii n. <br /> FOR_oF ICE USE: APPLICATION74_,� <br /> j(For Non-Transferable, Revocable, Sable) 1�0� <br /> - 4 21I <br /> ENVIRONMENTAL HEALTH PERMIT` ' 1 o pJ MP WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAID '`y <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/akrLsp(I T*4_k$hdr�W_Jscribed.This application is <br /> made in compliance wgl p J l Co Ordina e No. 1862 and the rules and regulations of the San J uin Local Health Dis ict. <br /> Exact Site Address L� _ City/Town <br /> Owner's Nam�y- /�� `�-^ f`/ Phone �7 -7 <br /> Address J LIZ 9 _ City_ 466 <br /> � � <br /> Contractor's Name �Lf� s _ License#� rT� Business Phone ._ --. _�f _ } <br /> Emergency Phone �� <br /> Contractor's Address '.. _ - g y - -- -- - - -� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - _ No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r,l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS lJ' <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 _ Public Domestic Well -- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information .. _. . -- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ _- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done -- <br /> PUMP REPAIR: Uttate Work Done a <br /> DESTRUCTION OF WELL: Well Diameter ._ . .____._... __ Approximate Depth . .. - <br /> Describe Material and Procedure <br /> r' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County N <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' g or sub-co 'ng signature certifies the following:"I cert if at i n the performance of the work for which this <br /> p suedW441 <br /> all e loy per ons subject to workman's compensati ws of California." <br /> I wi a Ins on pr' r 'n and a final inspection. <br /> i <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Rev rse Side) <br /> F R DEP RTMENT SE ONLY <br /> /( <br /> PHA <br /> Application alAccepted By—, Date c_//_2 <br /> Additional Comments: - - - —- - <br /> Phase II Grout Inspection ale III F' al Inspection r / <br /> Inspection By Date.......... ........ Inspection By Date `CJ / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE j $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Z_ <br /> LESS <br /> PRORATION <br /> PLUS I ------ -- --- <br /> PENALTY <br /> OTHER <br /> OTHER -- <br /> Received by Date Receipt No Permit 140 Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />