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Applico4.•. . I BeProcessedWhen Submitted Properly Completed, Be Sur 7�SSign acUMC&WELL <br /> ation. <br /> FOR OFFICE USE: APPLICATION 4f;;, .; . ' '' <br /> (For Non-Transferable, Revocab spr�ctat)I <br /> ENVIRONMENTAL HEAL ERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or in allthaaurktffiejrplsscgibed ;Thi application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and re Iy k_ <br /> gt�s t5i' S arZocai Health trict. y <br /> Exact Site Address?7 S f � �p <br /> Owner's Name Phone 9 �_ s <br /> Address <br /> city---- <br /> A3_3 <br /> } <br /> Contractor's Name - License #-� Business Phone_ <br /> Contractor's Address e Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDN❑ DESTRUCTION❑ IYI <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 1:1 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 ,Q <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> �1 I1 USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> UJi 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 v <br /> PUMP REPAIR: State Work Done47 G <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate epth <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 /> Home owner or licensed agent's signature certifies the ioliowing:"I certify that in the performance of the work for which this permit <br /> is issued, r 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 ca!I for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> q� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 (3� <br /> Application Accepted ey � Date <br /> Additional Comments: C� <br /> Phase II Grout Inspection Pha III Fina nspection <br /> Inspection By Date Inspection ByV te <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Ry January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> r� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 CACS , <br />