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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign tfApplication. <br /> FOR OFFICE USE: APPLICATION D E G 7 1981 <br /> (For Non-Transferable, Revocable, Suspendable) �4 <br /> I" C <br /> SUP" i <br /> ENVIRONMENTAL HEALTH PERMIT SM-1.11 -�-jt'. '� <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTH DISTRIC � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or ace No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /�� /9 V �� � City/Town Ly ),* <br /> Owner's Name OSC. evy.,voy we LA Phone R <br /> Address _p�6 C� .-_.._�,t-fP City k <br /> Contractor's Name License Business Phone A <br /> Contractor's Address Emergency Phone .`;_e7Q' :34 OFS <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - T No C? <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <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 /> DUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ 11DOMESTIC/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 �a.� <br /> Type of Pump tt 5 /�/�� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 <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 call for a Grout Inspect' prior to grouting and a final inspection. ,� <br /> Signed X' A - `Title: ;L�✓e1•.. Date: ;z _.Z �^ / <br /> (Draw Plot Plan on Reverse Side) <br /> ," FOR DEPARTMENT USE ONLY <br /> PHASE I R 11 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout InspectionP s III Final Inspectio <br /> Inspection By__.._ ag Date Inspection By � 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> 4S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13-1 <br /> Received by Date Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.,Box 21199 - STOCKTON,CA 95201 <br />