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- - <br /> Applications Will Be Processed When Submitted Properly Completed. BSureTo bign ineAppiludlivill. I <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PI L�'f <br /> ENVIRONMENTAL HEALTH PERMIT � <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY , +� .I`.+' <br /> nishereb made to the San Joaquin Local HealthDistrictforapermittoconstruct and/or instaHthewk,�he�reade <br /> Applicatio �cri �J. jtisapplication is I <br /> Y <br /> made in compliance with San Joaquin Count Ordnance No. 1862 and th r and rJgutions of the San JQacyuocl alth D' trict. <br /> Exact Site Address City/Town G�yT y. - '�•� <br /> i Phone ! <br /> Owner's Name <br /> Address r�� �-� 7� �City <br />` Contractor's Name License#�-t� Business Phone S� <br /> % Emergency Phone . <br /> Contractor's Address 7 1 !�� No ( /� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes v <br /> t TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> k WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ v <br /> k 0 0 DISTANCE TO NEAREST: Septic Tank � Sewer Lines � Pit Privy <br /> � <br /> Sewage Disposal Field Cesspool/Seepage Pit Qther <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ZL DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /C? <br /> ❑ IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfac Seal Installe y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f PUMP REPAIR: ❑ State Work Done <br /> f F DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t _ <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 /> I <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 /> lContractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> !!!! I ill all for a Grout Inspection rio o grouting and a final inspection. �9 <br /> Title: Date: <br /> Signed )C raw Plot Plan on Reverse Sid <br /> FOR DEP TMENT USE ONLY 7 <br /> PHASE I <br /> Date <br /> Application Accepted By—, <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> ? Inspection By Date <br /> Inspection By Date <br /> Fee Is DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July l &Received By July 31 +, <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ DATE <br /> �1DATE REMITTED AMT <br /> FEE &L <br /> LESS 7 g D <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER +n <br /> OTHER R <br /> Issua ce Date Mailed Delivered <br /> Received by Dae Receipt No. Per it No 1 <br /> APPLICANT ETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.sox 2009 STOCKTON,-CA 95201' <br />