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Applications Will Be Processed When Submitted Properly Completed0+9 <br /> 19Sltbe 131 l ti <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspe ) AUG WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or in p��+ <br /> made in compliance w�l San Joaquin�Ounty rd/I�n�ance o. 1882 and the rules and regulations of�hhe San oecal ealdthTDhis istrict. is <br /> Exact Site Address 1 ' d L, y�„, y �i <br /> Cit /Town <br /> Owner's Name 41'2r�—IVB <br /> Address e) � Pfiane CY- <br /> I <br /> Contractols;s Name � � � 1 city <br /> License# <br /> Contractor's Address )y Business Phone <br /> '- Emergency Phone <br /> Is Certificate Of Workman's Compensation Insurance on File With SJLHD? Yes !"_ <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ --� <br /> WELL CHLORINATION ❑- WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage'Disposal Field Cesspool/Seepage Pit <br /> Other F <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 <br /> 13DOMESTIC/PUBLIC 11Dia. of Well Casing <br /> DRIVEN Gauge'of Casing <br /> ❑ IRRIGATION- ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> IJ DISPOSAL 6 Type of Grout <br /> ❑ OTHER k Other Information <br /> ❑ GEOPHYSICAL + urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ^.e• <br /> PUMP REPLACEMENT. ❑ State Work Done ` <br /> PUMP REPAIR: MState Work Done <br /> DESTRUCTION OF WELL: i <br /> Well Diameter �' r ' <br /> Approximate Depth <br /> Describe Material and Procedure Y <br /> -. .� Ap <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the p rforma ceof the work for which this permit <br /> is issued, I shall not employ any-person in such manner as to become subject to workmari's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of-California." <br /> I wil call f r a,"t Inspection prior to grouting and a final Inspecti In. <br /> Signed X —CJ� — _ Title: <br /> Date: <br /> (Draw Plot Plan on"Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> " .. '- .. . <br /> .-Application Accepted By <br /> Additional Comments, Date 1[T <br /> Phase II Grout Inspection Phas III Final Inspection 77 <br /> Inspection By r Date -'w Inspection By . D �Z <br /> x ate <br /> #7 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT " <br /> PER SITE EACH, ❑ January 1 R 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 <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y Date Receipt No. - Permit No. <br /> ssuance ate Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENy1RONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKT4N,CA 95201 <br />