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FOR OFFICE USE: fp0 <br /> ApplicationsWIII Be'Processed When_Submitted Properly Completed. Be � <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspends " e ca�. <br /> � <br /> r - <br /> ENVIRONMENTAL HEALTH PERMIT 23 IRMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN "'01+'C IN U00AL <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or instal tEt4 rrT,18e BfT <br /> I r �cf {Cb�d.This application is <br /> made in compliance with San ounty Ori ante No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address `YY <br /> City/Town .xi�ecr <br /> Owner's Name <br /> Phone { <br /> Address City I1 <br /> Contractor's Name �}- __ License#, �[J�',�gusiness Phone 2— <br /> Contractor's Address * . Emergency Phone 1 `i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L/ No 'L 3 <br /> -� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ / rT`aY�oc✓ <br /> C3 ` 3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 4 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy <br /> Sewage Disposal Field Q Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> j ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br />' <br /> DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor ,_ <br /> Type of Pump P <br /> PUMP REPLACEMENT: 19 State Work Done I <br /> PUMP REPAIR. ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JJe <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for wis issued, I shall not employ any person in such manner as to become subject to workman's compensation lawContractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the wopermit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for f�. Inspection prior to grouting and a final inpeSigned X Title- Date <br /> (Draw Plot Pian on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ; <br /> Application Accepted By (_IYCA_ 3 <br /> Additional Comments: { <br /> Date ` <br /> Phase 11 Grout Inspection y Phase III Final Inspection <br /> Inspection ByL Date 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 /> AMOUNT <br /> FEE � y <br /> LESS y <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER "S!' - y '11'V L a' 1✓ <br /> "OTHER y <br /> du/¢ <br /> eceived by Dae - Receipt No. Permit No. Issuance Dat <br /> Mailed elivered <br /> • <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESr <br /> 1601 E.HAZELTON AVE.;P.O.Boa 2009' S70CKTON,"CA 95 .1 <br />