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Applications Will Be Processed When Submitted ProperlyCompimea. ee aure 1oryrr r+rc•+rr w <br /> 1 APPLICATION <br /> poRcopFICE USE: <br /> (Far Non-Transferable, Revocable, Suspendable) � pUlNP&WELL 'r <br /> ENVIRONMENTAL, HEALTH PERMIT <br /> Y f WATER QUALITY r <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with Spin Jo�quin bounty Ordi n e No. 1882 and the rules and regulations of the Sa Joa uin Loc Lte It District. <br /> City/Town G <br /> Exact Site Address /J / <br /> r Phone 7�r <br /> Owner's Name r <br /> City <br /> Address ,� Z_q ,z <br /> 1 License# Bus ness Phone? <br /> Contractor's Name _ _ , <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesRECNo <br /> TYPE OF WORK (CHECK): NEW WELL DENT N C] OTH OTHER ITI PUP INSTALLATION PUMP REPAIR❑ <br /> WELL CHLORINATION El WELL ABANDONMENT <br /> III REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br />{ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> II Property Line_f1Z) ( Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL !� <br /> 11 INDUSTRIAL � CABLE TOOL Dia. of Well Excavation <br /> . DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Q <br /> C3IRRIGATION 13GRAVEL PACK Depth of Grout Seal <br /> 13CATHODIC PROTECTION ❑ ROTARY Type of Grout X <br /> 11 DISPOSAL El OTHER Other Information <br /> 11 GEOPHYSICAL / Surface Seal installed By: <br /> 7. <br /> PUMP INSTALLATION: Contractor 15 <br /> Type of Pump 1 : 1, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ` ❑ State Work Done <br /> PUMP REPAIR: Tri— 'r"` <br /> —^—Well Diameter Approximate Depth <br /> � <br /> DESTRUCTION OF WELL: - <br /> } Describe Material and Procedure <br /> 1 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 /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f Contractors hiring or sub-contracting signature certifies the following:"l certify that f the performance of the work for which this <br /> permit is issued, I shall empl y persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspecti n prior to grouting and a final inspection. <br /> Signed Title: <br /> / eO Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepte y <br /> Additional Comme s: <br /> syeIl Grout Inspection / Ph Final <br /> (inai Inspection <br /> I' a .i��L Date C�-�j Inspection By Date <br /> :. <br /> inspection B �� <br /> ❑ ❑'PER SITE,,, El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivREMITBy uly 31 <br /> Fee is Due: ❑ ANNUALLY PER UNIT <br /> d BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t BASE EXPLANAT4ON DATE DATE REMITTED AMOUNT <br /> �L 9T <br /> FEE . <br /> F LESS <br /> PRORATION <br /> { PLUS <br /> PENALTY <br /> I. OTHER <br /> OTHER <br /> Dat • —Recetpt No Permit No.. Issuan Date m ailed De4ivered <br /> r•.,v <br /> Received by <br /> ` - APPLICA T—RETURN ALL COPIES TO_ `ENVIRONMENTAL HEALTR PERMIT/SERVICES 1601 E.HAZELTON AVE.,P:O.Box 2009 STOCKTON,CA 95201 <br />