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' Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOA`OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMF&WEl L 4, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal I the work herein described.This application is <br /> ' made in compliance wit San Joaquin o ntyr dinance o. 1862 t � rules and regulations of the San J a in Lofal ealth District. <br /> Exact Site Address wz;•' Ciity/TT wn ��G�6r�� „ <br /> Owner's Name + F'� ' Phone <br /> 'Address X.i, I City <br /> Contractor's Name ,1�� License Business Phone ale <br /> Contractor's Address ``.? 714 'f/✓< Emergency.Phone <br /> ' Is Certificate of Workman's Compensation Insu ce on File With SJLHD? Yes �/' No rr�1� _TYPE OF WORK (CHECK): NEW WELLDEEPEN E] RECONDITION❑ DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &' PUMP REPAIR❑ 1) <br /> REPLACEMENT❑ <br /> ' DISTANCE TO NEAREST: Septic Tank �i�/1 Sewer Lines t3�'t� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit d4-_o Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE v TYPE OF WELL <br /> ' ❑ BrJ.DUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ER'DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GPAVEL PACK Depth of Grout Seal "�— <br /> ❑ CATHODIC PROTECTION W/ROTARY Type of Grout <br /> ❑ DISPOSAL ® OTHER Other Information <br /> ❑ GEOPHYSICAL Surfac ea} Install� .B <br /> ' PUMP INSTALLATION: Contractor ' /� <br /> Type of Pump ' i H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ' PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL, Well Diameter Approximate.Depth <br /> �• d <br /> Describe Material and Procedure <br /> f' i <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 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 /> ' d Contractor's hiring or subcontracting 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." r s <br /> l <br /> I will call fora Or ut I ectiorn prior to grouting and a final Inspection. v <br /> ' Signed X M itle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I 47 <br /> Application Accepted By c <br /> Additional Comments: <br /> P pce.l'e�ar21 {�tspectionraspectiol <br /> ' _ Inspection By-7 Date <br /> Inspection <br /> Fee IS Due: ® ANNUALLY '.❑ PER UNIT. ❑ PER SITE s 0 EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31• ' <br /> ' t REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED d <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT C <br /> 1-3 <br /> FEE" —,v_� ..... 9 <br /> ' LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> Received by Date Receipt.No. Permit No. Issu ce Dat6 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKT ON,CA 95201 <br />