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Applications Will Be Processed When Submitted Prop rly Completed. Be Sure T4jkftT�e Ap lication. [J <br /> FOR OFFICE USE: APPLICATION mFi <br /> (For Non-Transferable, Re ocable, SuspendablA , 1, p � p&WELL <br /> ENVIRONMENTAL WATER HEALTH PERMIT Vtj1 L b-f } LOCAL <br /> (COMPLETE IN TRIPLICATE) QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit o construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin,Local H alth District. <br /> Exact Site Address O City/Town ``d_s <br /> Owner's Name +i Phone <br /> Address City <br /> Contractor's Name z3 License ft a­2 74::� 0prlBusiness Phone .� <br /> Contractor's Address C Emei gency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECON ITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRLiV <br /> REPLACEMENT❑ <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 /> S0DUSTAL ❑ CABLE TOOL Dia. of Well Excavation <br /> MESTIRIC/PRIVATE ElDRILLED Dia. of Well Casing <br /> M ESTIC/PUBLIC ❑ 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: S-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter A roximat Depth o <br /> Describe Material and Procedure <br /> m <br /> 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 forwhich this permit <br /> is issued, I shall not employ any person in such manner as to be ome subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the folio Ing:1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's co I pensation laws of California." QQ� <br /> I will all for a Grout Inspection prior to grouting and a final insplection. �1 <br /> Signed X Title: a/7.,✓T�r �j� Date: ILJJ <br /> {Draw Plot Plan on Re erse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase II Grout Inspection ha a III Final Inspection <br /> inspection By 1X\10 Date Inspection By Date G <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 $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECK <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE r 1 <br /> LESS 11 dh� r r <br /> PRORATION V <br /> PLUS L{ <br /> OF <br /> PENALTY <br /> OTHER <br /> OTHER <br /> __7 <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ET/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />