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ApplicationsWillBeProcessedWhenSubmitted Properly completea. " rego,,gnrjrrMANPI19 ioTu <br /> 1FOR OFFICE USE: APPLICATION t�� ��ll j <br /> (For Non-Transferable, Revocable, Suspen APR 2 1 I9 <br /> [� �C)MP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 1N TRIPLICATE) ' �[p�Si�Tin/ WATER QUALITY SAN .1OAQUiN LOCAL 061— 040 -t3 <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instNE-A61M h,QISTRIClIed.This application is <br /> made in compliance with San Joaqui County Ordinance No. 1862 and tf3ie ule an ulations of the San oaquin aI Health District. <br /> Exact Site Address � O 1 O City/Town �1p <br /> Owner's Nf�m �r��/] Phone <br /> Address f-� - s-V-- City <br /> Contractor's Name --F License Business Phone <br /> Contractor's Address �aSfG�f ""J PC& Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLIR DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONga PUMP REPAIR } <br /> REPLACEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Z60 _ Sewer Lines Pit Privy <br /> Sewage Disposal Field L Cesspool/Seepage Pit Other <br /> Property <br /> � Line/_W Private Domestic Well Public Domestic Well, Jr <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL JEL CABLE TOOL Dia. of Well Excavation <br /> ra " <br /> S DOMESTIC/PRIVATE 13 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 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ /1 A17 y _^Q— ,6.�6 _ kA- <br /> Type of Pump-'.e, Ot. 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 /> 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 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 call for a Grout Inspection prior,to grouting and a final inspection. <br /> �1 <br /> Signed X � {�+ <br /> Z22 A z &r-11 Title: (DaAe 2N _ Date: �y 40 /a r <br /> m (Draw Plot Plan on Reverse Side) A <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1 <br /> Application Accepted By r Date <br /> Additional Comments: <br /> Pha a II Grout Inspection / ha Ili F' al Inspection <br /> Inspection Bye, _ Date ( Inspection By Date <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 0 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .� <br /> A <br /> Received by Date Receipt No. Permit No. Is uance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />