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Applications Will Be Processed When Submitted Properly Completed. Be Sure To S'lyn he Application. <br /> FOR OFFICE USE: APPLICAT)ONr c (-,;' T;' <br /> `�3 <br /> - (For Non-Transferable, Revoaf6 to V P&WELL <br /> yyyJJJ <br /> ENVIRONMENTAL HE ,H PERMIT_ �g$ <br /> (COMPLETE IN TRIPLICATE) WATER QUAL Y 11 AU G 6 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal I the r rein described.This application is <br /> f�� yy <br /> made in compliance with San Joaquin County Ordinance o.1862 and the ul s and�wati�u`���Ltrip loin L al Health District. <br /> Exact Site Address fJ �s _ <br /> Owner's'Name ` p`�.v Phone -�f p 2� 6 . .' <br /> Address .: Gity� <br /> Contractor's Name e License# Business Phone-; <br /> Contractor's Address ' ergency Phone 7�� G; 2247.•.•y, " <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN-0 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT53" C <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy p <br /> Sewage Disposal Field Cesspool/Seepage Pit Other Z <br /> 6Property.Line_ _ Private Domestic Well Public DomesticiWell 4 <br /> INTENDED USE TYPE OF WELL i - i - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL �I Dia- of Well Excavation i� I <br /> ❑ DOMESTIC/PRIVATE 11DRILLED Dia- of Well Casing <br /> 1:1 DOMESTIC/PUB LIC 11 DRIVEN i` Gauge of Casing j <br /> ❑ IRRIGATION`S �`-�-; --v-- -1U-GRAVEL PACK ., Depth of.Grout Seal <br /> ❑ CATHODIC PROTECTI60/1 7;��--0�❑ROTARY , Type of G'rdut" I <br /> ❑.DISPOSAL � 0 OTHER r% Other-information 1 <br /> ❑ GEOPHYSICAL . ` Surface Seal Installed By:- <br /> _PUMP INSTALLATION: _ Contractor AJ 4 f i <br /> Type of Pump -- �f ; H.P. —- <br /> . <br /> PUMP REPLACEMENT: ❑-State Work pone <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that I have preparedithis application and that the work will be done in accordance with San Joaquin County <br /> -ordinances,_state_laws,and_rules_andtir_egulations of the San Joaquin Local Health_District. i <br />` <br /> Homeowner 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 persons subject to workman's compensation laws of California." <br /> I will FVI fa�Gro.t i nsoection prior Jo grousing and a final ins ection. <br /> Signed X "� _-I - Title: Date: <br /> (Draw PIo an on Revers Side) <br /> FOR DEPARTMENT USE ONLY 4`1 <br />` PHASE I .: _ <br /> i <br /> ce <br /> Application Accepted By �' -- - v `'� �` -- Date 6I <br /> Additional Comments: { <br /> Phase II Grout Inspection a 111 Final Inspection t <br /> Inspection By bate Inspection By t Date d�" �. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> • BILLING REMITTANCE $ ! 'REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE, y 5 <br /> LESS i <br /> PRORATION I <br /> PLUS <br /> PENALTY ? �� <br /> OTHER - 3 <br /> OTHER <br /> Received by Date Receipt Nof Permit No. lissuabco D to Marled Delivered. -. <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />