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Applications Will Be Processed When Submitted Properly Completed. Be 60 eSignt,ThE'Apolica'tldn.0FOR OFFICE USE: APPLICATIONt <br /> s. (For Non-Transferable, Revocable, Suspenda � <br /> ,1UL 9MAAP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAIN' i0r"�(�l�l J O"AL i <br /> 5� fCT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install wEsiWK r Ibed.Thisapplicationis <br /> made in compliance with San Joaquin CountOrdinanc No. 1862 h rules and regulations of the Sroaqu n Loc I Health D' trict. <br /> Exact Site Address i r City/Town �� C 1" �y V! Cli I <br /> Owner's Name 711tN `r' Phone $ <br /> Address Cit- C-N� t <br /> "Z <br /> Contractor's Name - License# -Q."usiness Phone 257 -7 <br /> Contractor's Addk [• Emergency Phone —; <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes E. No <br /> TYPE OF WORK (CHECK): NEW WELL®"— EEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL+J---°-� <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines mit Pit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well F <br /> INTENDED USE TYPE OF WELL / .> <br /> 1❑ NDUSTRIAL r ❑ CABLE TOOL Dia. of Well Excavation—f <br /> DOMESTIC/PRIVAT ❑ DRILLED Dia. of Well Casing <br />='IRRIGATION <br /> B L I C ❑ DRIVEN Gauge of Casing %:Z <br /> �AVEL PACK Depth of Grout Seal <br /> OTECTION ❑ ROTARY Type of ut <br /> ❑ DISPOSAL ❑ OTHER r-lwY <br /> 11GEOPHYSICAL Surface Seal lnstalle y <br /> PUMP INSTALLATION: Contractor x5 4 <br /> Type of Pu . H.P. .} <br /> PUMP REPLACEMENT: ❑ State Work a y s <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - f <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 theSanJoaquin Local Health District. <br /> _ f <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." t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that iri the performance of the work torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws_of.California," <br /> I will call for a Grout I ection prior to grouting and a final inspection. <br /> 45� <br /> Signed X ,' le: L`1 x-% 5 -_+ Date: ! �J <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY .� I <br /> PHASE <br /> Application Accepted By �� Date <br /> Additional Comments: <br /> a II Grout Inspection ffG P se III Final Inspection -7 I <br /> Inspection By Date q { 1 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 /> BASE EXPLANATION ' BILLING REMITTANCE AMOUNT DUE CHECKED ' <br /> T DATE DATE' REMITTED _ AMOUNT + <br /> or <br /> FEE ,/ <br /> LESS f k <br /> PRORATION r ,M1.'�• _ $ <br /> PLUS` <br /> PENALTY d - <br /> OTHER t <br /> OTHER ell <br /> Received by Date Receipt No. Permit No. - Issuan e D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA1'ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 4 <br />