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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The ApplNW4 �98� <br /> ~ _ FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) <br /> Mp 4'W - „ LOCAL <br /> E` ENVIRONMENTAL HEALTH PERMIT HEAL TI A LiSTRICT <br /> (COMPLETE IN TRIPLICATE) t� s� AT R UALITY �(3 /20 —Q Z <br /> Application is hereby made to the San Joaquin Local Health Districtfora p” efTriit to construct and/or i nstail 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 SanJoaquin Local Health District. <br /> Exact Site Address City/Townes <br /> � � f <br /> Owner's Name h Phone ..-6`212 <br /> 4 CL O <br /> Address =� - City <br /> Contractor's Name License#�U _ Business Phone �_7hr <br /> Contractor's Address Emergency Phone W <br /> k Is Certificate of Workman's Compensation'Insurance on File With SJLHD? YesLI-1 No <br /> TYPE OF WORK (CHECK): NEW WELL 1:1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT R' OTHER ❑ PUMP INSTALLATION IR' PUMP REPAIR❑ <br /> REPLACEMENT❑ '� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ANDUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t ❑ DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: A State Work bone - '� <br /> PUMP REPAIR: ❑ State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameterpprq�ximate Depth <br /> Describe Material and Procedure �J <br /> It <br /> I 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 <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 /> I will all fora Grout l prior io grouting and-a final Inspe on. - <br /> Signed X Title: 'MI. .- - x- ,Date: Zey� 6' <br /> i (Draw lot Plan on Reverse,Side) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASEI � ©T1 <br /> Application Accepted Z�M� Date <br /> "Odditional Comments: <br /> Phase II Grout Inspection h el nal Inspection <br /> Inspection By Date Date Inspection B Date - -- <br /> ' Fee Is Due: ❑ ANNUALLY -❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 'o BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �^ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY V <br /> OTHER <br /> OTHER <br /> --Received by Dat4 Receipt No.'-- `- - Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />