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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure Two Sign The Application. A� <br /> FOR-OF. USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) R <br /> ENVIRONMENTAL HEALTH PERMIT � &p&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin C unty Ordinance No. 11362 and the rules and regulati ns t Joaquin Lo I alth Di tri <br /> Exact Site Addresss� �P� `i f'� � ity ojw� <br /> n�+` <br /> Owner's Na el,r Phone <br /> Address �� °1 �C] <br /> City /�- <br /> Contractor's Name License#� Business Phone <br /> Contractor's Address G73` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> ! WELL CHLORINATION ❑ WELL ABANDONMENT)d OTHER ❑ PUMP INSTALLATIONA- PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage Disposal Field Cesspool/Seepage Pit Other y } <br /> Property Line Private Domestic Well _ Public Domestic Well 3 <br /> INTENDED USE TYPE OF WELL t ri <br /> ❑ INDUSTRIAL ,4 CABLE TOOL Dia. of Wel{ Excavation <br /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> t ❑ DOMESTIC/PUBLIC El DRIVEN' Gauge of Casing I <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> l ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor kA 0 <br /> 7. <br /> Type of Pump H.P. z <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter AP roximate Depth 11 <br /> Describe Material and Procedure <br /> ii a Z_ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Home owner or licensed agenl's signature certifies the following:"{certify that in the performance otthe work forwhich 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit issued, I shall em PI persons subject to workman's compensation laws of California." <br /> I ill II r a Gr In n prior to grouting and a final inspection. �V <br /> Signed.X c - Title: 4 Date <br /> .w <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI �Q <br /> Application Accepted By + i Date <br /> Additional Comments: Q J '� 1 <br /> a <br /> P II Gf gut Inspection has If inal Inspection <br /> Inspection By �—' Date .Inspection By � Date <br /> Fee IS Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju[y 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ` <br /> FEE .� -�� _ �/ 3 <br /> LESS /\ f <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> Received by Receipt No. <br /> P Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETIfRNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .� <br /> x 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />