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�f' ^ Applications Will Be Processed When SuAPPLICAProperly <br /> TIQNpletea.ese aufe ��y­ <br /> pk dFFICE USE: f' eTocable, Suspendable) <br /> ��-8„� (For Non-'Transter�}„�,�t pUp11p&WELL , <br /> a;dp ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY rk <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made totheSan Joaquin Locadmanceh�ostrBt2andora phe rules and regulatlo softtheSanJoaquinl,LdCalcHealdthTDistrhis alpplicationis <br /> made in compliance with San Joaquin Count O City/Town <br /> Exact Site Address 2 <br /> / Phone <br /> Owner's Name <br /> City <br /> Address License#r Business Phone <br /> Contractor's Name �� ` y�r Emergency Phone 1 <br /> Contractor's Address� ---- - No <br /> Is Certificate of Workman's Compensation Insurance on File With 5JLH4? Yes DESTRUCTION[] <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION 13 PUMP REPAIR❑ �n <br /> i C V' <br /> REPLACEMENT❑ I <br /> Sewer Lines � — Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank -E Cesspool/S�epage Pit Other J <br /> Sewage Disposal Meld �i� Public Domestic Well <br /> Property Line�O�- Private Domestic Well s� <br />[; TYPE OF WELL H <br /> INTENDED USE Dia. of Well Excavation <br /> 11. INDUSTRIAL ❑ CABLE TOOL ,i <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN �� <br /> 11 IRRIGATION � GRAVEL PACK <br /> Depth of Grout Seal � <br /> r� ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION 13 Other Information C` <br /> ❑ DISPOSAL 13 OTHER <br /> Surface seal Installed By: <br /> ❑ GEOPHYSICAL <br /> .+ <br /> tor trac � <br /> i PUMP INSTALLATION: ConH.P. <br /> f Type of Pump <br /> f PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter <br /> Approximate Depth <br /> e <br /> DESTRUCTION OF WELL: <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 Joaquin County <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 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 for which this <br /> permit is issued, I shall employ per s subject to workman's compensation laws of California." <br /> I will C i for a Lit pecti Ior to grouting and a final inspection. 1 <br /> Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse I e) <br /> z <br /> FOR DEPARTMENT USE ONLY <br /> jPHASE i Date <br /> Application Accepted By <br /> Additional Comments: seAll Final Inspection > <br /> Phase II Gro t inspection ����� Date <br /> Date �� `� Inspection By <br /> Inspection By , <br /> ❑ ❑ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITBy uly 31 <br /> Fee IS Due: ANNUALLY PER UNIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 6 <br /> LEss <br /> p PRORATION <br /> { PLUS <br /> I PENALTY <br /> �4 OTHER <br /> 1 OTHER <br /> ! 0 <br /> q Date Receipt NO Permit No. Issuance'ate Mailed Delivered <br /> - Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 201 <br /> eaauCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />