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S v, t v „ 6 <br /> Applications Will Be Processed When Submitted Properly Complete DO SWel"Sj,4he A- a <br /> FOR OFFICE USE: APPLICATION ) <br /> (For Non-Transferable,Revocable,Suspendable) )�&WELL <br /> ENVIRONMENTAL HEALTH PERMITmp � � „ �j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> CAL <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or hol M11h,W4141ribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the/pules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ry C Y I�ctG��1� / i �cY City/Town �� <br /> Owner's Name h u— Phone a <br /> Address �:y ( e Gf h�e City Pj [y <br /> Contractor's Name CC(41/a)(. ���nU License#'� � Business Phone ��17 7 3 <br /> Contractor's Address —3-V0 !.(M� /`/ &C9 Emergency Phone <br /> Is Certificate of Workman's Compensation In rance 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❑ i <br /> DISTANCE TO NEAREST: Septic Tank loo Sewer Lines 1 Ivo Pit Privy <br /> Sewage Disposal Field IC/0 Cesspool/Seepage Pit 6W 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 V ' <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 <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 Insp tion prior to grouting and a final inspection. <br /> Signed X J* Title: � r Date: 47,1-1 r'*7,? <br /> —(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By— <br /> Additional <br /> y Date <br /> Additional Comments: <br /> ,,'Phase H Grout Inspection Phase Ill Final Inspection <br /> Inspection By a fes' A Imo'}A 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 3 L4 <br /> Received by Date Receipt No. Permit No. Issuan 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 />