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= ` %:,_Applicatlon-s•WiII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.FOR OFFICE USE: .. APPLICATION <br /> l (For Non-Transierable, Revocable,Suspendable) ! <br /> L�rENVIRONMENTAL HEALTH PERMIT <br /> r (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. fl3pi n <br /> made in compliance with San Joaquin ountyy?Ordinan�ce/�o. 1862 and the rules and regulations of the San oa�m l�1,H�a�t�l1 District. �I <br /> Exact Site Address r- -r-��V Jae 2�e� City/Town m-: �'� <br /> Owner's Name Phone 3.-3 11-3 A? C'At <br /> Address ' i-! <br /> City -Cc--a- <br /> Contractor's Name _. 'a1 .�-c�c �� License#��X373 Business Phone 3 <br /> Contractor's Address 3 d 22. _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes [/ No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> ` REPLACEMENT2' V ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_ Pit Privy,--- -Y <br /> i Sewage Disposal Field Cesspool/Seepage Pit I Other <br /> ,.Property Line Private Domestic Well f 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 /> r ❑ GEOPHYSICAL„, Surface Seal Installed By <br /> l PUMP INSTALLATION: =Contractor <br /> { �Type of Pump H.P —r cam- <br /> 'PUMP REPLACEMENT: L' State-Work_Done- _ _ _ t <br /> PUMP REPAIR: :- ❑ State Work Done <br /> DESTRUCTION OF,WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' 06 <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 /> r <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit Y { <br /> is issued,'il•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:slued, I shall employ persons subject to workman's compensation laws of California." <br /> II I will c 'for Grout lnsp tion pr�toouling and a final inspeclion. i / [Y _ <br /> Signed X - - LTifle: � Date: 1�(L� <br /> (Draw lot Plan on Rev se Side) <br /> �­FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I Application Accepted By �- -c7-p'�1 ti <br /> Date <br /> Additional Comments: <br /> I <br /> Pha a 11 Grout InspectionIII Final Inspection ` <br /> i. Inspection By Date Inspection By <br /> h Date <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT °El PER SITE ElEACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING <br /> BASE EXPLANATION REMITTANCE <br /> $ REMIT <br /> PATE DATE REMITTED, AMOUNT DUE CHECKED <br /> AMOUNT <br /> Ate_._ 1 <br /> PEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by - �Date Receipt No. Permit No. Ise Date acted' Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�J� <br />