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Applications Will Be Processed When Submitted ProperlyCompleted. Be sureTo sign IneAppiwazrvrz. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT j s PUJ-AP&)KELL <br /> f �� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1--� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San.Joaquin Local Health District. <br /> Exact Site Address /.5— �� - City/Town <br /> Owner's Name _ L <br /> Phone <br /> Address r City } <br /> Contractor's Name- License#"���f71 Business Phone <br /> Contractor's Address //�� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fi a With SJLHD? Yes ll­ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> 5 <br /> REPLACEMENT❑ w <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 /> INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> ( DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> _,.,,� <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 InfoImation i <br /> ❑ GEOPHYSICALf Surface Seal Installed By: <br /> t. <br /> PUMP INSTALLATION: Contractor r'r� '4� <br /> Type of Pump L H P' / N <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> 11 State Work Done j <br /> PUMP REPAIR: � s <br /> DESTRUCTION OF WELL- Well Diameter �_+� Approximate Depth <br /> .1 - Describe Material and Procedure <br /> 4 <br /> I hereby certify that I have prepared this application and tliat the work will be donein accordance with.San Joaquin-County <br /> l 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 wbrk for whsc_h this permit b <br /> is issued, l 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 certity that in the performance of the work torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />` 1 will for -out Igspection prior to grouting and a final inspection. > <br /> Signed X <br /> Title: 1 Date: -910 <br /> I , 4 (Draw Plot Plan on Reverse Side) <br /> F j ~ OR DEPARTMENT USE ONLY <br /> PHASE 1 Date 9 <br /> Application Accepted By ` ^ <br /> Additional Comments: - <br /> k a , Phase II Grout Inspection Phas Ill Final Inspection 1 <br /> { pate Inspection By Date <br /> z-� <br /> !!! Inspection By <br /> ANNUALY ❑ PER UNIT ElPER SITE El EACH ❑ January 1 &Received By January 31 ❑_July 1 &Receiv REMITd By <br /> 31 <br /> Fee Is Due: ❑ <br /> ( BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 'YLf6 <br /> FEE <br /> LESS <br /> ` PRORATION - <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> i OTHER <br /> 0 5'343 f` L(�)] <br /> Date Receipt No. Permit No. Issu nce Date Mailed Deliv red <br /> Received by $520 - <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16p1 E.HAZELTON AVE.,P.P.Box 2009 STOCKTON,CA <br />