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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) f' <br /> PUP:1P &b'VELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> nw.cWi c9rrinli�ne with San Joaquir�,County Ordinar�e No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> J. <br /> �Fjj L� ,... _ ii <br /> Site"A d _ ` � I City/Town <br /> — y <br /> Phone . � 3' Y" <br /> Owner's Name ,. ' <br /> Address — � r 1� 1 � City <br /> Contractor's Name cense#/ <br /> g - * " 1 ?,Business Phone _ <br /> �; '"Iit` � ' � Li ��>� <br /> Contractor's Address ,• Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL ISI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ J�•'� <br /> DISTANCE TO NEAREST: Septic Tank "L> 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 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 `J <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal L' <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout �_11T3 LL <br /> c <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: ❑ 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 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 /> Signed XL_E 1 cL'Lr'� Title: —I t/' Date: LT_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date— <br /> Additional Comments: <br /> _Phase II Grout Inspection G ha a III Final Inspection . <br /> Inspection By� •''""'--- Date -Z_ <br /> — Inspection By���G-� 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> -- - C%C% <br /> i cv <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L< 1 _ n <br /> Received by Date Receipt No. Permit No. I suan a 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 />