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Applications WIII Be Processed When Submitted Properly Completed. Be SLr oSi n h Aliltppl 5i . <br /> FOR OFFICE USE: APPLICATION I <br /> t <br /> (For Non-Transferable, Revocable,Suspendable) ` �MQ�WA <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Jo uin Co L my Ordinance No. 1$62 and the rules and regulations of the San Joaquin cal Healt District.. <br /> Exact Site Address y n City/Town _ �! 0-- 5 3� <br /> Owner's Name -CJPhone_ <br /> Address , { City <br /> Contractor's Name x r License# Business Phone <br /> Contractor's Address Emergency Phone -V <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes 4---' No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 13R "PUMP INSTALLATION I� PUMP REPAI ` <br /> _ REPLACEMENT❑ Da <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 /> C1 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ODOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other lnformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION_: Contractor <br /> Y Type of Pump H.P.f <br /> PUMP REPLACEMENT: YR. StgW Work D e .�ij <br /> PUMP REPAIR: 09001ate Work Done <br /> DESTRUCTION OF WELL: WeIP 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 /> iordinances, 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 forwhich 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 /> r Contractor's hiring or sub-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 /> I wit call for a Groulspection prior to grouting and a final inspection. s <br /> Signed X - ' Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE <br /> Application Accepted By `-+- _ Date <br /> Additional Comments: - - <br /> Phase II Grout Inspection PI se III Final Inspection _ <br /> Inspection By-M CL Date Inspection B Date <br /> Fee is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July, 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCES AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE (. I�� /( � t off C[ <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER L 30+-�2' _A1rw Owf►Ct• <br /> (r <br /> I rJ v c.av k <br /> OTHER GCv j k.jn �`rt!`'vM'7� �:!%vf-Cti .; Z�! v'!� <br /> i., '-'•` -`Received by Date Receipt No, - Permit No Issuance-Date Mailed Delivered L - •- <br /> I APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />