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Applications Will Be Processed When Submitted Properly Com f. 6e So Sign TheAp lion. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable,Revocable, SuspendatlQ4G 2 7' 19 &WELL ! <br /> ENVIRONMENTAL HEALTH PFMT�CAQUIN LOrAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r HEALTH MSTRICT <br /> Application is hereby made to the San Joaquin Local H2alth District fora permit to construct.and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1.862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address c�+'J City/Town �5��` <br /> Owner's Name " " s Phone rest's_ <br /> Address s r3 s . City .�4./�r <br /> Contractor's Name t License#00r19A'9/U Business Phone <br /> Contractor's Address °" Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 14i`ez�v No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTO' <br /> DISTANCE TO NEAREST: Septic Tank3 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 ❑ CABLE TOOL Dia. of Well Excavation-" <br /> & DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l <br /> ❑ IRRIGATION ❑ GRAVEL PACK- Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Y <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of alifornia." <br /> I will r a G ut rior to grouting and a final inspectio <br /> Signed X Title: Date: � /�; <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted'By ~/Ll Date <br /> Additional Comments: <br /> Ph se II Grout Inspection 3 s III final Inspection " <br /> Inspection,By , .Date Inspection,By Date <br /> "Fee I's Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July31 , <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED i <br /> GATE DATE REMITTED AMOUNT <br /> FEE S a <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER - - <br /> OTHER « <br /> Received by- ate Receipt No.':; Permit No. Issuance Date Mailed .Delivered.. i <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 i <br />