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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O.FFWt E USE: <br /> APPLICATION ! o16 x <br /> (For Non-Transferable, Revocable,Suspendable) 4 Pt1MP WELLe ^W <br /> r.- <br /> ENVIRONMENTAL HEALTH PERMIT �er <br /> (COMPLETE IN TRIPLICATE) WATHP`QUALII,Y �I th wo rk hein d scribed.This a lication isApplication is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or rnst I� PP a <br /> made in compliance w'th San Joaquin Cin y Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health Distract _� t <br /> Exact Site Address y City/Town <br /> Owner's Name Phone <br /> Address 7 , City J, <br /> Contractor's Name t� ii License#E� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <6 4 Pit Privy <br /> Sewage Disposal Field e+ Cesspool/ eepage Pit Other <br /> Property Line Private Domestic Well © Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- <br /> DOMESTIC/PRIVATE <br /> xcavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing l <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r /._,c <br /> ❑ IRRIGATION , GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ni/ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: I�/�✓1' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 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 forwhich this <br /> permit is issued, I shall employ per ns subject to workman's compensation laws of California." <br /> I wl!l_cgl for a G t I ect' or to grouting and a final inspection. <br /> Signed X Title: 4a E61 Date: ss <br /> (Draw Plot Plan on Revers - ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE L0'�, '�� <br /> Application Accepted By Date <br /> i Additional Comments: <br /> Ph a rout I pection U Phase III Final Inspection <br /> Inspection ByDate Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r FEE 3 <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lissuan6e Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH 13EAMITISERVICES 1601-E.HAZELTON AVE.,P.O.'Box 2009 STOCKTON,CA 95201 <br />