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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Appli a io <br /> FOR OFFICE usE: APPLICATION ° q <br /> '�- (For Non-Tran1. sferable, Revocable, Suspendable) 111T 13pL�IC11 8,w ELL <br /> +' ENVIRONMENTAL HEALTH'PERM ANri <br /> (COMPLETE IN TRIPLICATE) � (�'�,� Q�Y .� E? 1lST�t? C.T 11, 16 <br /> Application is hereby made tothe S al ealth�istrict or t str��ta or„�nstllthework herein described.This application is <br /> made in compliance San Joaquin,C�Ounty ,Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. <br /> � <br /> Exact Site Address r . O 15ity/Town ,,4 sj,�-r- i <br /> ° w <br /> Owner's Name 'OT'1� <br /> Address City- �__ 1• <br /> Contractor's Name MYffijN_ sC,5%. 4 b C-,� License 2 >1 5,3 Business Phone- - j v7;� <br /> Contractor's Addre'js, Wit;_ C�f �- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes i--- No �} <br /> TYPE OF WORK (CHECK): NEW WELL.IR— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 'Z <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 03-- PUMP REPAIR❑ <br /> REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines C5 Pit Privy <br /> Sewage Disposalfield Cesspool/Seepage Pit Other <br /> -Property Line 46 .Private Domestic Well Public.Domestic Well. - - - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /:L <br /> ❑ ❑ p .. <br /> IRRIGATION GRAVEL PACK � Depth of Grout Sea! :5_G <br /> ❑ CATHODIC PROTECTION UV-ROTARY Type of Grout _ .' 4 <br /> ❑ DISPOSAL ❑ OTHE Other Information r� <br /> ❑ GEOPHYSICAL Surface Seal Installed # <br /> PUMP INSTALLATION: Contracto CD1 17, c Z5 k% X06 44 4!�I1 5 <br /> Type of Pump '�j ;ti H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done + <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> x <br /> Describe Material and Procedure <br /> 1 p <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 f <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 is issued, I shall employ persons subject to workman's compensation laws of California." , <br /> I will call for a Grout Inspection prior to grouting and a final inspection. G <br /> Signed Date. <br /> Title: di <br /> - "-(Draw Plot-Plan on Reverse-Side)�^ - - <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE Application Accepted By a `-� Date <br /> Additional Comments 1 <br /> Phase Grout In pec / se I Final Inspection N <br /> Inspec By ems- a �f a�Q ! nspection By Date 4q <br /> " I <br /> Fee Is Dile[ ElANNUALLY PER UNIT ❑ PER SITE EACH ❑.January 1 8 Received By January 31 ❑ July 1 &Received By July 31 + <br /> REMIT i <br /> BILLING REMITTANCE <br /> BASE EXPLANATION r AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ... �[ OZ.) <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER k \ <br /> Received by D to - Receipt No.' Perm#t No. - '-Issuance Date Mailed Delivered j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />