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Applications Will Be Processed When Submitted Properly Completed. Be S 5i ri--h4_1*pdicV1ori.ri. <br /> FOR OFFICE USE: APPLICATION 'M <br /> �1 <br /> (For Non Transferable, Revocable, Suspendable) JAN 14 M8l&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SANt'''( <br /> {COMPLETE IN TRIPLICATE} WATER QUALITY ( l it t 'Eji <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install ti eisr �"fhis application is <br /> made in compliance with San Jpoa uin Count Ordinance No.1862 an t e rules and regulations of the San Joaquin L cal Health District. <br /> Exact Site Address i(0 L9 er s ; RA/V/`✓/� 1M City/Town es ' "L) <br /> Owner's Name Phone <br /> Address n� City � '� �f <br /> Contractor's Name o cs� I-,-) License#V?V/0 Business Phone &� "c22o <br /> Contractor's Address c2a I7W//U Emergency Phone SLetmok. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- No { <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR` <br /> REPLACEMENT❑ F <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC E] 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 <br /> PUMP REPAIR: State Work Done t. 1>t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <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 /> 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will c ivr a ro n�p tion prior to grouting and a final inspeci'i;010 <br /> - <br /> f <br /> Signed X Title: Date: <br /> (Draw P Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I w1}y��1 <br /> i vUli[�u .� l l <br /> Application Accepted By <br /> Additional Comments: Date <br /> i Phase It Grout Inspectiona e I Final Inspection <br /> Inspection By Date Inspection B Date f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE F-1EACH El January 1 & e"ed <br /> By January 31 C3 July 1 &Received By July 31' <br /> REMIT S <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED - <br /> C� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ .. <br /> PLUS 4 <br /> PENALTY <br /> I i <br /> r OTHER <br /> I <br /> I <br /> OTHER I <br /> i <br /> lReceived by Date Receipt No. y Permit No. Issuance Date - Mailed Delivered <br /> l4R APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />