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1. Applications`Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> FOR 6WICE USE: / APPLICATION <br /> tQ� 0'V4 (For Non-Transferable, Revocable, Suspendable) r <br /> P(JMP&WELL <br /> f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY + <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San"Joaeggin County 0 djna_nce No. 1862 and the rules and regulations of the San Joaqui Lo a Health District. " <br /> Exact Site Address 3 T� ® City/Town j <br /> Owner's Name 1-sr jt.�C II/r �•.f t y Phone % 1 <br /> Address Y Cityt •s p+� ���' c ,� <br /> Contractor's Name 2License#f 3�Business Phone_ L 7d7g <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes� No f <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El RECONDITION LJDESTRUCTION❑ ��'. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 1 � F <br /> Sewage Disposal Field 'Cesspool/Seepage Pit Other <br /> Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r <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 In Iled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done .p <br /> PUMP REPAIR: State Work Done A UA <br /> 1 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will cal for a Grout Inspection prior to gr ut ng d a fl' 1nspect'ol <br /> Signed XDate: l f <br /> (Djaw Plot Plan on Reverse Side) <br /> s <br /> F R DEPA TMENT USE ONLY <br /> PHASE I ° <br /> Application Accepted By Date 7 �d <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By 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 /> EASE EXPLANATION BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> "LESS <br /> PRORATION-,,. <br /> PLUS <br /> PENALTY (J OT HER <br /> M <br /> i' <br /> OTHERVr <br /> f <br /> �t 3 / 7 IQ <br /> Received by Date Receipt No Permit No. k uance 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 /> 4 <br />