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E <br /> 1 <br /> Fir <br /> Applications will de Nrocessea when sudmittea Property L;GMpletea. pe Sure t o Sign The Application. <br /> FOR OFF1 ,E USE: APPLICATION <br /> tA_ (For Non-Transferable, Revocable, Suspendable) <br /> G Y ` IJM L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fpr a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordi ante No. 1862 and the rules and re illations of the San Joaquin Local Health District. <br /> {Exact Site Address Jsra _r.d� l� -4.t+c 4x 6. t?#-A✓ '7t R. `drate7; City/Town <br /> Owner's Named c-fes rR _` � __-- Phone <br /> F <br /> Address ` y �_�r � t L �*^ z,� City Sotor Contractor's Name 1D-W 4/� License is /q3-71-.V"Business Phone Lam.-3- 7 _ <br /> Contractor's Address ter, '' _ .., - lifts Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ, HD? Yes , No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ 1/ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy (� <br /> , Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> +❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> iF <br /> r ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION © GRAVEL PACK Depth of Grout Seal i 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T ~' <br /> ype of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> F4'PUMP <br /> GEOPHYSICAL Surface Sea] Installed By:INSTALLATION: Contractor '�' u • ------W,c <br /> Type of Pump— -- Sce_.4 H.P.. - <br /> FPUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REP4hMR: State Work DoneArt e VL— <br /> ;DESTRUCTION OF WELL: Well Diameter pproximate Depth <br /> Describe Material and Procedure <br /> F., 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 forwhich 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 /> a <br /> Contractors hiring or sub-canitacting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." l' <br /> I wi11 call for a Grout Inspect' pr r t gro r- g and final inspection. <br /> Si ned X : M1f* ft°7«..a; . d tt itle• y,, <br /> g off- Dale- <br /> i7 (Draw Plot Ian on Reverse Side) _F <br /> FOR DEPARTMENT USE ONLY N <br /> PHASE I <br /> Application Accepted By j• - ._L.r__, �..5 ! ;, ,a:_:_.�c� _ Date <br /> Additional Comments: <br /> � PhaseJl Grout Inspection P1e <br /> aIR Final Inspection <br /> r •y r f- t :i� {� <br /> Inspection By Date t _ Inspection By '' Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 & Received By July 31Fi, <br /> - <br /> BILLING REMITTANCE REMIT <br /> 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> Fi <br /> FEE w 1 <br /> �, L-1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> F,, <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Received by pate Receipt No. Permit No,- Issuance Date r Mailed Delivered - <br />