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Mntcanons willBeProcessedWhen Submitted Property Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r-or Non-Transferable,.Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT & LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY • <br /> Application is hereby made to the San Joaquin Local HBalthDistrictforapermittoconstructand/orinstallthe rk.h Ind cribed. isapplicaiionis <br /> made in compliance with S Joa uin Count inance No. 1862 and th le <br /> s nd regulations of the Sa <br /> Exact Site Addres quin Loc I Healistrict. <br /> City/Town �.LC <br /> i <br /> Otrner's Name P to <br /> Address Phone <br /> Contractor's Name City <br /> Licens Business Phone <br /> Contractor's Address ` <br /> IsCertificate of Workman's Compensation hn1guipice on File With SJLHD?Emergency Pho e <br /> Yes No <br /> TYPE OF WORK (CHECK): NEW WELL ZK DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP-INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank. <br /> ,Sgwer Lines Age Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> ert Lin�_y Other <br /> Pro <br /> I P Y. 7 Private Domestic Well/QD '�Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br />�, ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> pOMESTIC/PRIVATE <br /> f <br /> �DOMESTIC/PUBLIC DRILLED Dia. of Well.Casing <br /> DRIVEN Gauge of Casing + <br /> El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ROTARY <br /> 0 DISPOSAL Type of Grout <br /> ❑ GEOPHYSICALKOTHER Other Informatio <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT: C3 State Work Done <br /> PUMP.REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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,.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 forwhich this <br /> permit is issued, f shall employ Persons subject to workman's compensation laws of California." <br /> I for G Ion prior to grouting and'a final inspection. <br /> Signed X <br /> ate: <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f <br /> Application Accepted By �`'� <br /> Additional Comments: Q Date <br /> P as II Grout Inspection a'e.11l Final Inspection <br /> Inspection By Date Inspection By Date ) <br /> i <br /> Fee IS QUe: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January.l 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING . REMITTANCE $ <br /> REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKEb ' I <br /> IEt ( AMOUNT <br /> FEE f7 0443 <br /> 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by _ Date Receipt No. Permit No. � <br /> Issuan a Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESM <br /> 1ii01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 85207 <br />