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' ae�p <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure T n n <br /> FOR OFFICE USE: APPLICATION UH <br /> (For Non-Transferable, Rerbcable,Suspendable) <br /> h <br /> { ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY - SAN '�O'�'Q�'�IN L��AL <br /> (COMPLETE IN TRIPLICATE) H +�j �F j. 1.F• QM <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstallthework. e l e application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address _5�� V'AKe R ' City/Town ` <br /> Owner's,Name Phone 3�—'"�� '• <br /> Address /Q n'1 ; City fa/.0 A <br /> Contractor's Name License#,979&19 'Business Phone <br /> Contractor's Address 42-nia3 Emergency Phone 5 P <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ _ No <br /> TYPE OF WORK (CHECK): _NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑• WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR19 <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 /> ❑ INDUSTRIAL ❑ 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done ° <br /> r <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, <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit M <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 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 /> r I will ll for a Grouto Inspection prior to grouting and a final inspect <br /> Signed X: Title: _ ti Date: <br /> l/ (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments:. <br /> Phase it Grout Inspection hase III Fina spe tion <br /> Inspection By Date Inspection By - <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN4T - -❑ PER SITE ❑ EACH, ❑ January 1 &Received By Januar 1 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> p J DATE DATE REMITTED AMOUNT <br /> I` FEE - <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 131J d-� I )-Yle/ 1 ,� <br /> Received by Wate Receipt No. Permit No Issuance-Date Mailed Delivered ! <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />