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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION �4 I <br /> _(For Non-Transferable, Revocable, Suspendablel PUNAP & WELL <br /> ENVI.9 <br /> j0NMFNTALLJJJIEALTH PERM T <br /> (COMPLETE IN TRIPLICATE) • (j1:M'TEIyQOA'[1TY ) G I'� <br /> Application is hereby madeto the San Joaquin Local Health District for permit to consfruct arYd/or install thework herein described.This application is <br /> made in compliance{ith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San rloaquin Local Health District, <br /> Exact Site Address ! 1�f�/ r !- t T i C t� City/Townh l= <br /> Owner's Na e L il Aj '-J 'y (� Phone 3 `' �� 7 <br /> Address y 7 1—=�-)- c III / e 4 city k<= r-_hkj � <br /> Contractor's Name�J// f. :., `. .'' �-�� License ff/ :?L r..3 Business Phone —7 y 1 �+ <br /> Contractor's Address ��^ S.-l� !u i7-! Emergency Phone -7 Y .,�' /�3`'r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELLQ' DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ -PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank I 1 Sewer Lines 1.5Z: Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 1 <br /> Property Line 3 v Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavat' <br /> E DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �✓e <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0--ROTARY Type of Grout — <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL :.7 Surface Seal sta d By: <br /> PUMP INSTALLATION: Contractor I ov— 4 <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County y� <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 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 /> Contractor's hiring or subcontracting signature certifies the following:1 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" <br /> I will <br /> call for a Grout Inspection prior to grouting and a final Inspection. <br /> Signed X . Title: t�l �x w.y...t Date: - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> >' <br /> Application Accepted By '� �ytv--- � Date <br /> Additional Comments: <br /> hase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> 5 <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 /> BILLING REMITTANCE E <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R W.Med f Dald Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1W1 E.HAZELTON AVE.,P.O.am 21109 STOCKTON,CA 9601 <br />