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Applications Will Be Processed When Submitted Properly Lornpirly � <br /> `W.POR G'FFICE USE: <br /> APPLICATION i C <br /> lej <br /> (For Non-Transferable, Revocable, Sus IT J o 0 1981 P MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ?st?- 04'0-C16 , <br /> r WATER QUALITY GAN ii�''�(j j i� L-00AL. <br /> (COMPLETE IN TRIPLICATE) LZ4.y3 ST`.�v�� permit to f - � <br /> Application isherebylnadetotheSanJoaquinLocalHealth Dii+strict for a ermittoconstructand/ori 1 Ilt o k r I scnbed.Thisapplicationis <br /> made in compliance with fan Joaquin County Ordinance No..18 alothe�u s;nd regulati City/TownSan al Health district. <br /> �. 6 <br /> Exact Site Address II t - <br /> !, Phone <br /> Owner's Name _1 City <br /> ir <br /> Address > 1 <br /> ' V*y vy. Licens �it Business Phone <br /> Contractor's Name ,� <br /> � � � � O�.".�,! �rgency Phone <br />€ Contractor's Address .rte- s�rcz��' - No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR© <br /> REPLACEMENT 11 INI Pit Sewer Lines _ Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> x, Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USEII TYPE OF WELL <br /> k ❑ INDUSTRIAL '� P ❑ CABLE TOOL Dia. of.Well Excavation �l <br /> k ❑ DOMESTIC/PRIVATE ! ElDRILLED Dia. of Well Casing N <br /> �1\❑ DRIVEN Gauge of Casing <br /> j 11DOMESTIC/PUBLIC _ Grout Depth of Seal <br /> IRRIGATION GRAVEL PACKto <br /> l ❑ CATHODIC PROTECTION <br /> ❑ROTARY Type of Grout <br /> i ❑ DISPOSAL ❑ OTHER Other information �.L <br /> Surface Seal Installed By: ^ <br /> ❑ GEOPHYSICAL , r,. Z w L�' <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> I C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done { <br /> Well Diameter Approximate Depth f4 <br /> DESTRUCTION OF WELL: t <br /> Describe Material and Procedure <br /> have prepared this application and"that the work will be done in accordance with San Joaquin County la <br /> I hereby certify that I P P <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ! Home owner or liceri'ised 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 ed age <br /> any person in such manner as to become subject to workman's compensation laws of California." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that f the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." T <br /> call for Grou Insp tion'prior to grouting and a final in tion. <br /> Title:�� Date: d <br /> Signed X —.� ��I� <br /> (Draw Plot Plan on Reverse Si ) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PfiASE I 1 sr� Date <br /> Application Accepted 8y <br /> Additional Comments: ,4j Phase III Final Inspection <br /> Phase Ii Grout Inspection Date <br /> !� <br /> Inspection By Date Inspection By <br /> �I By 31 <br /> ❑ PER UNIT PER SITE ❑EACH El January 1 &Receive January 31 ❑ July 1 8 ReceivRJuly <br /> Fee Is Due' ANNUALLY EMIT <br /> REMITTANCE AMOUNT DUE- CHECKED <br /> BjASE EXPLANATION BILLING <br /> DATE ITTED AMOUNT <br /> IM <br /> FEE ` <br /> LESS II <br /> PRORATION III <br /> PLUS <br /> PENALTY r <br /> r <br /> OTHER �I <br /> OTHER <br /> Receipt No. Permit Na Issuanc Dat Mailed Delivered <br /> Received by 'I�,Date CA 95201 <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 570CKTON, <br /> .APPLICANT—RETURN Al COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES y w- <br />