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rappRcattonsWill Be Pracessed When Submitted Properly Completed. Be SuSign The Application. <br /> FOt OFFICE USE: APPLICATION r <br /> (For Non-Transferable, Revocable, Suspendable) DEC -10 1979 S� <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUNA VXELI W <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT W <br /> Application is hereby made totheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is W <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the Sar Joaquin Local Health District, <br /> Exact Site Address O L <br /> ' City/Town <br /> Owner's Name 6 (2 S <br /> Address Phone—LY-8— <br /> Contractor's Name , / City CSC N <br /> License# 19., 07 <br /> Contractor's Address �QO 3 �, 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 11PUMP REPAIRL� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Other <br /> P Y Private Domestic Wel! Pubiic Domestic Well <br /> INTENDED USE <br /> ❑ INDUSTRIAL TYPE OF WELL <br /> ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> IR DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 1111 IRRIGATION Gauge of Casing <br /> GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION <br /> 11 DISPOSAL ROTARY Type of Grout .— <br /> ROTARY <br /> El GEOPHYSICAL Other Information <br /> - <br /> PUMP INSTALLATION: Contractor Surface Seal lnstalfed By: <br /> Type of Pump X <br /> PUMP REPLACEMENT: 11State Work Done H P <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Q <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 <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:"1 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 /> I will ca r a Grout Inspec' n prior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: A-.2-7- <br /> (Draw Plot Plan on Reverse Sido) <br /> PHASE FO DEPART NT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date � � <br /> Phase 11 Grout Inspection <br /> Inspection By Date P s 111 Final spection <br /> Inspection BDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 33 1:01 Lily 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> FEE �' AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �g--133T <br /> Received by a!6 7 No.ate <br /> Receipt P Permit No. Issuan3ce Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON DetCKTO <br /> AVE„P.O.Box 2009 STOCKTONp1j <br />