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ApplicationsWill Be Processed When Submitted Properly Compieted. Be S � <br /> ;; o`Sigr <br /> FOR OFFICE usE: t'The�A Il !do <br /> APPLICATION APR � 8i <br /> ^ <br /> ,. (For Non-Transferable, Revocable, Suspendable) A f i�Q.� <br /> ENVIRONMENTAL HEALTH PERMIT 'IIP&WELL <br /> t (COMPLETE IN TRIPLICATE ;` `AA ,J0A C <br /> } WATER QUALITY ALT QU1N LOC, <br /> Application is hereby made to the San Joaquin Local Health DiAU <br /> strict for a permit taconstruct and/or install the work her rr �- <br /> 4 made in compliance vrit�'ht,San�a�in County Ordinance N 1862 and the rules-and regulations of the San JOaquiL al � alth Dhstis application is <br /> Exact Site Address �� <br /> — City/Town "I <br /> Owner's Name too EN ©Q� <br /> E Address r/ S s IIIPhone <br /> F Contractor's Name CityQ <br /> — <br /> d/ITal <br /> p�A License Business Phone <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ . -WELL,ABANDONMENT,El _, � <br /> REPLACEMENT❑ OTHER ❑ . RUMP INSTALLATION PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank iSewer Lines I <br /> Pit Privy`. Sewage Disposal Field Cesspoo[/Seepage Pit <br /> Property Line Other <br /> p Y Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> 16 DOMESTIC/PRIVATE Dia. Of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION.. ❑ ROTARY,- . <br /> 11DISPOSAL Type of Grouts <br /> ❑ OTHER Other Information t <br /> El GEOPHYSICAL Surfa a Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: El H.P. <br /> State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter II <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> - liome-owner or licensed agent's signature certifies the followin _. y p ` a - <br /> is issued, I shall not employ an 9="I certif that in the erformance oof the work for which this permit <br /> P Y Y person in such manner as to become subject to workman's compensation laws of California." g <br /> Contractor's hiring orsub-contracling 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 California." <br /> ! will c r a Gr ut In ectio rlor grousing and a final inspection. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY n_ <br /> PHASE ! <br /> Application Accepte By <br /> Additional Comme ts- Date <br /> Phasq II Grout Inspection <br /> Inspection By Ph se II Final Inspectio <br /> Inspection By---NAkDate Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE �J � � AMOUNT <br /> LESS �! <br /> PRORATION <br /> PENALTY �, .••.. .j-. �,�,». -wf»,.... a. ,..a -r ... ,.,�++.�.,,, .mow ._...- — - - - <br /> OTHER [[ <br /> OTHER <br /> Received by Dat Receipt No <br /> r P Permit No- Issuance Date - Mailed Defiveretl 4 <br /> APPLICANT—RETURN ALL COPIES TO:. -.ENVIRONMENTAL HEALTH PERMIT/SERVICES. <br /> - '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT13N_Ca 411ni <br />