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Applications Will Be Processed When Submitted Pro erluretTo I The Application. <br /> FOR OFFICE USE: APDL J V is <br /> (For Non-Transferable, cable, Suspgqen��dab,lgqe) 071 <br /> ENVIRONMENT, ALkS9) y1M6' 80 C <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY /��1 G <br /> Application is hereby made to the San Joaquin Local Health District fora permit teAktrt)h-f0',huc[li )��vork herein described.This application is <br /> made in compliance with�p uiD Coupty flidlnartCe No. 1862 and th rules�1�I I9tionns of the San oa uin I Health District. 1 <br /> Exact Site Address (J !�{'- /'f�tIIO,� �j+p�V tl�' City/Town N <br /> Owner's Name ;F0A_P.0 J Wo J& XTot.1 9�/0`x-3 <br /> Phone <br /> Address - City__ �0 <br /> Contractor's Name ,L� License# Busiress Ehone <br /> Contractor's Address 1'I Emergency Phone /`j'•S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 133-' <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 -00 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: R'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 /> Home owner 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 MOM r sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit I shall employ s subject to workman's compensat' laws of California." n <br /> 1 I o Inspection no to g_ rOutinnng and a final insp <br /> y eaYi"� <br /> Signed X Title: Date: dr " <br /> (Draw Plot Plan on Ffeverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI o <br /> Application Accepted By DateO <br /> Additional Comments: <br /> Phase/aII Grout Inspection Phase 111 Final Inspection <br /> Inspection By WA Date Inspection By ;�) . q�QAn.rn_� Date 3-.2 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS T J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Dyh qs' <br /> Received by Date Receipt No. Perrot No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />