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ri <br /> (For Non-Transferable, Revocable,Suspendable) AP <br /> .val Be Processed When Submitted Properly Completed. Be T rlat' j� <br /> F( APPLICATION J f <br /> R 3 �1 <br /> ENVIRONMENTAL HEALTH PERMIT R rnp ELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN J;OTAQUIN LOCAL „ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install't��44of& eQiSfto Td.This application is <br /> made in complianW <br /> y With San Joaquin County Ordinance No.1862 and the ruI s a d re u ions of the San Joaquin Local Health District. <br /> Exact Site Add S /� > � l y/ own <br /> © x <br /> Owner's Name \ k' Cs ly.i Phone D 2,7 5 �~rr <br /> Address 3 :3 %` 1 'r - '� <br /> _ City t-. <br /> Contractor's Name /A C:_, sn License#193;2 C-3 Business Phone -Y 7 <br /> Contractor's AddresEj;&%?Xt `5 81. ., Emergency Phone ae'"o" ~ _ <br /> Is Certificate of Workman's Compensation-Insurance on File With SJLHD? Yes No <br /> I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines is Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL p <br /> rf 4 <br /> ❑�USTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ly <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 7-_ <br /> 0-TrRIGATION 0-'GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �OTARY Type of Grout ` <br /> ❑ DISPOSAL ❑ OTHER Other information . <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4 <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 /> 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 far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X CakxTitle: Date.<ZtiZl�.,9 Z c <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ® Date <br /> Additional Comments: <br /> Phas II out Insp tion P III Final spection <br /> Inspection By ��� � Inspection By 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 AMOUNT DUE CHECKED <br /> �// DATE DATE REMITTED AMOUNT <br /> FEE i 3 �\ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER j <br /> OTHER <br /> � s3© L4 ILI 13 <br /> Received by Date Receipt No. Permit No. lissuante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r <br />