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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) PUAAP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY G�Q� � > ' w <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 Joaquin County Ordinances No. 1862 and the rules and regulations of the San Joaquin Local Health Djstrict. <br /> Exact Site Address&AG Vc [A�1.� �f— City/Town <br /> > /' 17 <br /> Owner's Name R Phone 7(7 — / 4' <br /> Address City 4G' <br /> Contractor's Name w License# `} q <br /> Contractor's Address ! 6�i.J� Business Phone V 7 <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank.-SG <br /> p t Sewer Lines.��{- Pit Privy - <br /> Sewage Disposal Field C" P f <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well qv 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 r- <br /> ❑ IRRIGATION , GRAVEL PACK Depth of Grout Seal c? <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Cn <br /> ❑ DISPOSALa <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B e2il <br /> PUMP INSTALLATION: y `�� `n <br /> 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 <br /> 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 rsons subject to workman's compensation laws of California." <br /> 1 'll call for ut Ins ct' prior to grouting and a final inspection. <br /> Signed <br /> Title: Gy Date: <br /> (Draw Plot Plan on ReveLie Side) <br /> FOR DEPARTMENT USE ONLY �? '7 <br /> PHASEI �A � 7���7 / <br /> �l\)�ti 11 <br /> Application Accepted By � D <br /> Additional Comments: wv� <br /> hase II Grout Inspection P s I11 Final Inspection <br /> Inspection By Dated Inspection By Date - <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date / �� � �—` <br /> Receipt No. Permit No. I uance Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />