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Applications Will Be Processed When Submitted Properly Completed. TiTplio�►� <br /> FOR OFFICE USE: APPLICATION ILL'�iJJ{ <br /> {For Non-Transferable, Revocable,Suspen HAY 2 2�WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN 3' + , N LOCAL <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstruct and/or inst1AEA r h S1W ed.This application is <br /> made in compliance with San Joa uin CouWy Ordinance No. 1862 an r s and regulations of the San Joaquin Health District. <br /> Exact Site Address f�/ J— l -�J ��� � - City/Town -21 <br /> Owner's Name --M-5r Phone <br /> Address City "' <br /> Contractor's Name `� f License# V..ykr 6 Business Phonef!v'1 <br /> Contractor's Address F, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurang 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❑ <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 iPCc cr¢r,c?� ,c+ catGor <br /> PUMP REPAIR: ❑ State Work Done <br /> r. <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 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 Ins ction prior to grouting and a final inspection. <br /> Signed XGc +� �. Title: rJ � Date: e� L) <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI _ <br /> Application Accepted By r e-C, Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pt asen (�� <br /> Inspection By Date Inspection By Date ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July eceived By Jul <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> t <br /> J 4 <br /> FEE J L` W-4 <br /> LESS <br /> PRORATION N0 <br /> PLUS /� v IVY <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dat4 Receipt No. Permit 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 9520 <br />