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Applications Will Be Processed When Submitted Properly-ComTo Si nth c on, <br /> FOR OFFICE USE: APPLICATION AUG t � K <br /> (For Non-Transferable, Revocable,Suspendable) <br /> t ENVIRONMENTAL HEALTH PERMIT $At' jor,QUIN fLl .WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> HMTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin CouU <br /> y Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -aG co LAY t,�CJ 9 <br /> City/Town I—,SC A /0M <br /> i J <br />{. Owner's Name V,_ 7 wN S o Phone <br /> Address r� LASLJ RCY City Of S C. 0 <br /> Contractor's Name License# S /G}j° Business✓ Phone <br /> Contractor's Address <a � .c`lc-�J cOLOA1-s Emergency Phone S­{ r 4:5 <br /> t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD4 Yes No'; <br /> TYPE OF-WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION I J 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 PitOther <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ia�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ( y`r1 1 w`-o �v. i <br /> l <br /> Type of Pump—_5 H.P. <br /> PUMP REPLACEMENT: ❑ State-Work Done �' } <br /> PUMP REPAIR: ❑ State Work Done <br /> 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. I <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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 4 <br /> I will call for a Grou3 Inspection prior to grouting and a final inspection. <br /> Signed X Title: Gt -R Date: r G Z- a <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se Ili Final Inspection <br /> Inspection By e,_ Date B Inspection p Y ON Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT _ <br /> BASE EXPLANATION DATE DATE - REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE D� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER (. <br /> q, <br /> OTHER I <br /> ` 4 <br /> Received by Date Receipt No. Permit o. Issuance Oale Mailed Delivered - �r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 952016,,.Sj <br />