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Applications Will Be Processed When Submitted Properly Completed. Be Sure F igf��,4"djia�ioV. � '! H <br /> IF ROFFICE USE: APPLICATION ��--�� <br /> (For Non-Transferable, Revocable,Suspendable) E� ' M 'WELL <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY SAN Jrf UIN LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the w"Eik e Idea.i&eTdF;�CsTapplication is <br /> made in compliance with S n oa ul Count Or ante No.1862 and the ruled regulations of the San Joaquin ocal Health District. <br /> Exact Site Address 1W 111 aZAI V City/Town a C <br /> Owner's Name Phone <br /> Rd-p-OP1017 <br /> Address City n1 <br /> ' � -��v� <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes "`1 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 <br /> Property Line Private Domestic Well Public Domestic Well <br /> t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation E <br /> 51-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <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 <br /> PUMP REPAIR: ® State Work Done .e Gs�� pZj <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ---------- 1 <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 �3 # <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." I <br /> �} <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 11 for a o ction prior to grouting and a final inspec _ <br /> Signed X R TTitle: a pale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY G� -1 <br /> PHASE I Date r�a`3 <br /> Application Accepted By <br /> Additional Comments: e <br /> Phase R Grout InspectionI I Final Inspection S <br /> Inspection By I`f\ In Date Inspection By ase Date 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SfTE ❑ EACH ❑ January 1 S Rece ed By January 31 - ❑ July 1 &Receivedl By July 31 <br /> BILLING REMITTANCE $ REMIT i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 1pate I Receipt No. Permit No. Issuance Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 t <br />