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Applications Will Be Processed When Submitted ProperlyCompletes tse sure Ioalgn ,rscs.r11u­ . i I <br /> APPLICATION <br /> FOR OFFICE USE: <br /> - (For Non-Transferable, Revocable, Suspendable)M SCAN <br /> ,. <br /> IT <br /> ENVIRONMENTAL HEALTH PERf <br /> . �o S- /f , W T R UpALITY <br /> (COMPLETE IN TRIPLICATE Cs-fa pre ft n <br /> Application is hereby made to the San Joaquin Local Health District f ra r l o onsrctand/orinstalltheworkhereindescribed.Thisapplicationis <br /> o. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance N <br /> City/Town ' <br /> Exact Site Address , o, <br /> Owner's Name <br /> 1 Phone ` G�� Q <br /> City <br /> Address t — r' <br /> Contractor's Name icense#. �I Business Phone`_' <br /> Contractor's Address rnergency Phone <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <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 /> ❑ l pd,§TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 92"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 L4 <br /> 1:1 GEOPHYSICAL s Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d' <br /> Type of PumpH.P' 4 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> j- PUMP REPAIR: <br /> 11 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure A <br /> i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Q <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 forwhich 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, l shall employ persons subject to workman's compensation laws of California." <br /> Grout Igspection prior to grouting and a final inspection. <br /> Signe Title: <br /> Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPAR NT USE ONLY <br /> PHASE I Date zzl46d <br /> FApplication Accepted By- <br /> PH <br /> y <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph I I al lnspection <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY [3 PER UNIT El PER SITE ❑ EACH El January 1 &Received By January 31 C1 July i &ReceiveREMITuIy 31 <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �J DATE DATE REMITTED AMOUNT <br /> I FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> [, OTHER <br /> + OTHER <br /> kill <br /> Received by <br /> Date Receipt No- Permit No. Issuance Dale Mailed Del' d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br />