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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication <br /> icE USE: <br /> APPLICATION <br /> DFFj <br /> (For Non-Transferable, Revocable,Sus <br /> e3 a E�) ; <br /> �" 3 �� FJ&WELL <br /> f ENVIRONMENTAL HEALTH P IT <br />' �' WATER QUALITY NOV 100 1980 <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe'S nJ quinLocalHealthDistrictforapermittoconstructand/�+oprinnhs���talltherw�ork�hiereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulatit�49 tACC JQWa4 uAQQALHealth District. <br /> Exact Site Address 1A CI�,�T H DISTRICT <br /> Owner's Name 7 :>1 N —Rn QE—_> g.i2 Phone <br /> Address —1 nepBcy E. Ll(3I✓I3T4 •IJ <br /> ' S . City ren <br /> Y �!nt[ R1M� License# 03 _ Business Phone — <br /> 48 <br /> Contractor's Name ��L�.h i <br /> Contractor's Address — Emergency Phone <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❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I V� Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ OASLE TOO..L�--- - -Dla.of Well Excavation <br /> ❑1 INDUSTRIAL .:. d..c�'«� - - <br /> I DOMESTIC/PRIVATE ❑ DRI.LLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC Y❑ DRIVEN :, G2ugeof Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth;pf Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> + ❑ GEOPHYSICAL "Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (>IE G - _ <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> 1. DESTRUCTION OF WELL: Well Diameter - Approximate Depth <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 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:'•1 certify that in the performance of the work forwhich this <br /> € permit is issued, I sh mpIoy persons subject to workman's compensation laws of California." <br /> - — I <br /> f wil c a G nsp coon prior to grouting and a final inspect! yy <br /> Signed X Title: Date: <br /> F (Draw Plot Plan on Reverse Si e) <br /> ! <br /> t FOR DEPARTMENT,USE ONLY p <br /> E PHASE I <br /> Application Accepted By Date <br /> Additional Comments: F F � <br /> Phase 11 Grout Inspection Phase7111'Final inspection <br /> irVi UIr' 1t �{� -�� / lee) <br /> Inspection By Date f £ Inspection By DalefJ1 / <br /> Fee Is Due: ❑ ANNUALLY– ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE COY <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY - <br /> It OTHER <br /> OTHER <br /> p 'Received by _ Date Receipt No.- Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-.Box 2009 STOCKTON,CA 95201 <br />