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e — Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: - �, APPLICATION J <br /> (For Non-Transferable, Revocable,Suspendable) I <br /> =r ENVIRONMENTAL HEALTH PERMIT ' UMP&WELL <br /> jCOMPLETE 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 Joaquin County Ordinuice No. 1862 and the rules and regulations of the San Joaquin Local Health District. ,i <br /> Exact Site Address g -g' vc City/Town <br /> r <br /> Owner's Name ,rT U iN. — ¢�-� ��AnL.O-=---- �� _ Phone <br /> Address �9 �i° ' _ City <br /> Contractor's Name LicenseBusiness Phone <br /> Contractor's Address ro Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Gth SJLHD? Yes t-�_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j <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 WELL41 <br /> ❑ IN�USTR[AL 13 CABLE TOOL Dia. of Well Excavation <br /> WO DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I <br /> 11 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: a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. l� <br /> PUMP REPLACEMENT: ❑ State Work Do <br /> PUMP REPAIR: ❑ State Work Dane <br />`a 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 /> Home owner 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 w'f calf' r a Grout I ection prior to grouting and a final inspection. <br /> I q <br /> Sig Title: CrIL-VI—RA. Date: 7- <br /> (Draw Plot Plan on Reverse Side) <br /> EQB DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection U Final Inspection p,,, <br /> Inspection By Date Inspection By Date OU <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑-PER SITE ❑ EACH . ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ft BILLING REMITTANCE <br /> BASE EXPLANATION DATE PATE, REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> M FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 912 6. <br /> Received by Date Receipt No. - - Permit No Issuance Date Mailed ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE:,P.O.Boa 2009 STOCKTON,CA 95201 <br />