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Applications Wi a #t o e s �,Y1� n uk� f i1t 1� perly Completed.Be SureIto 5ign.The Applfcatitin. LLJ <br /> s_ 4 i ,.-¢ U1 <br /> FOR OFFICE USE: ill AP ATION <br /> a �(iC.�r�crtt 3oterable, Revocable,Suspendable) AWS <br /> A&VIRONMEN - L HEALTH PERMIT <br /> � R QUALITY _i r:QU?�J �.�ie,�iL <br /> (COMPLETE IN TRIPLICATE) ,a 1 ~`'' �, 3 1 <br /> Application is hereby made to the San Joaqu cal �� tt a permit to construct and/or install thew + ix�ld�scr application is <br /> made in compliance with San Joaquin County, c 0. 186 2 and the.rules and regulations of the San Joa in Local kiealth District. <br /> Exact Site Address City/TownJ7-5r34 <br /> ms+ /, <br /> Owner's Name <br /> II.,S0'v. - Phone 7 7 <br /> City " <br /> Address 5` `� �r <br /> "�h Q -,. License# B sine Phone <br /> Contractor's Name � � <br /> Contractor's Address I <br /> " Emergency Pho <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOI1V PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank, <br /> Sewer Lines Pit Privy 3 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation j <br /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia of Well Casing <br /> ElDOMESTIC/PUBLIC 13 DRIVEN <br /> 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 s' S, rface Seal Install By: <br /> PUMP INSTALLATION: Contractor w^- r <br /> —Type of Pump �lti H.P. ' <br /> PUMP REPLACEMENT: - <br /> f❑ State Work Done <br /> PUMP REPAIR: ❑'State Work Done,, C>6 I <br /> DESTRUCTION OF WELL: ,Well Diameter Approximate Depth <br /> Describe'Material and Procedure I <br /> 4 <br /> r <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 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 l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> all fora Grout Inspectio prior to.grouting and a final in on. <br /> ! y I u `Date: <br /> r <br /> Signed X ---' Title: <br /> $, (Draw Plot Plan on Reverse de) <br /> � •1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By - .., <br /> Additional Comments: <br /> Phase It Grout Inspection Pas It Final Inspection <br /> r :a c Ins ection B Date " <br /> Inspection By 1. IRS Date P Y , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '-❑ EACH_ ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByl July 31 , <br /> BASE EXPLANATION BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br />,r DATE DATE REMITTED AMOUNT <br /> t FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ' PENALTY. <br /> I OTHER <br /> OTHER 7 /e <br /> ' Date Receipt No <br /> Permit No. ssuanc Date Mailed - Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />