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r Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Ap 0r24 1981 tO <br /> FOR OFFICE USE: APPLICATION SAN <br /> (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT H I�l� icT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin�Co/�nty Or�mance No. 1862 nd the rule and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ll /L/ 17 �/,�Ii�� City/Town p <br /> Owner's Name Phone ✓�/�� / <br /> Address City <br /> Contractor's Nam .a License Business Phone <br /> Contractor's Address EmergencyPhope +� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ —� <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 /> ❑,�, I USTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> I' 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 /> Tey fp mp H.P. C <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of-California." <br /> I will ora Grout In n prior to gr uting and a"al Inspection. <br /> Signed X Date: <br /> (Draw PlotP a o everse Side) , <br /> el <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 91D <br /> Application Accepted By �JDate <br /> Additional Comments: <br /> Phase it Grout Inspection P as II Fl Inspection <br /> Inspection By Date Inspection By Date 10-13-W. <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE 11EACH ❑ January 1&R ed 8y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r 33sco <br /> Received by Date Receipt No. Permit No. I uance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />