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'�"P plica w Will Be°rocesser�W S tied Properly Completed. taeSure Io sign InempprrUnuv+l <br /> PP --� ,, PLICATION <br /> rFORA_OFFICE USE: Q�f G �? <br /> SA <br /> h+ { �on- ferabie, Revocable,Suspendable) pump&WELL <br /> ' J0A ENVIRONMENTAL HEALTH PERMIT <br /> ATN J] LQ � WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Local <br /> Application is herebymadetotheSanJoaquinLocall-I�It�iDistrictforapermittoconstructand/orinstallthework herein described.This application is <br /> made: <br /> compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the SarJoaquin acal Health District. <br /> ExactrSite Address City/Town _� Gh <br /> Cryl Phone <br /> Owner's Name <br /> City <br /> Address <br /> License# usiness Phone <br /> Contractor's Name <br /> Contractor's Address4Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> N0 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ "WELL-ABANDONMENT-❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPIiACEMENT❑ <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 /> TYPE OF WELL <br /> + INTENDED USE t <br /> ❑ II D <br /> IeUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ 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 Information <br /> LS11� urface Seal Installed By: <br /> E 11 GEOPHYSICAL - G11 <br /> PUMP INSTALLATION: Contractor <br /> Type f Pump H.P. <br /> I� tate Work-Done <br /> G PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that.l have prepared this application and that the work.will be done.in accordance with San Joaquin County : <br /> 1 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 otthe work for which this permit <br /> ii is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," <br /> � <br /> Contractor's hiring or"sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> p' II permit is issued, l shall employ persons subject to orkman's compensation laws of California-" <br /> 1 w' for a Grout Ins ectio or to routin and a final inspeciiap' J f <br /> IJ Title: Date: (� <br /> Signed X <br /> i] {Draw Plot Plan on Reverse Side) <br /> ORD ARTMENT USE ONLY <br /> PHASE 1 2 Date `s <br /> Application Accepted By <br /> j II Additional Comments: <br /> r Phase 11 Grout Inspection ha III Final Inspection , 'l <br /> it Date Inspection By Dat X <br /> r � Inspection By <br /> I <br /> Ej Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jui eiv REM ITuiy 31 <br /> + - ` EXPLANATION BILLING REMITTANCE $ AMOUNT O CHECd ByKED <br /> ] BASE DATE DATE REMITTED AMOUNT <br /> .S <br /> ? I <br /> FEE <br /> II <br /> •. LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> "+ OTHER <br /> ii � - <br /> II . <br /> OTHER <br /> o, Permit No. Issuance Date Mailed Delivered <br /> I! Received by Date Receipt N , - <br /> 2009 STOCKTON,CA 95201 <br /> II APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.BOY <br />