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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Th ipAliication. l <br /> FOR OFFICE USE: APPLICATION ® 90.7 <br /> (For Non-Transferable, Revocable, Suspendable) UZ <br /> I'LfMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SM t0f-,QU1N' LOCAL <br /> (COMPLETE IN TRIP ICATE) WATER QUALITY HEALTIA DISTPICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compli2nce with San Joaquin County Ordin ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name 9, f Phone <br /> K13 -.33Y 9F <br /> Address <br /> City- `7'YICJ.,,ft7_'!;�' <br /> License# �- n i <br /> Contractor's Name . <br /> _ �a�.��a� Business Phone ��,� �/��'� <br /> Contractor's Address a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X _— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ C)(/frSSU" <br /> DISTANCE TO NEAREST: Septic Tank - /00 Sew ines 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> I 19 VC <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing // <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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, t shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractors 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 II for a Grout Insp ctio for to grouting and a final inspection. <br /> Signed X Title: Date: f <br /> (Draw PI Plan on Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> Application Accepted•B -- Date <br /> Additional Comments: <br /> P las 11 j3rout Inspection se III Final Inspection a <br /> -` n <br /> Inspection By Date l�' �� Inspection By Date �� 2 <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. - AMOUNTDUE CHECKED <br /> DATE DATE �yREMITTED AMOUNT <br /> FEE d <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY 14. <br /> OTHER <br /> OTHER <br /> Received by ate Receipt No. Permit No. Issu nce Dati Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />