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Applications Will Be Processed When Submitted Properly Completed. Be'urge f6jk9b iTJ eUppfficaudn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspenda A 0 C JL5A 09&ELL <br /> ENVIRONMENTAL HEALTH PERMIT oS-(Do- <br /> (COMPLETE IN TRIPLICATE) V 4y W T R QUALITY SAti <br /> TW <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install t ,eP!d%T9V, This application is <br /> made in with San Joao ip C unty Ordinance No. 6.an the rules aQd rula 'ons of the San Jpaquin Lo al Health District- <br /> Exact Site Address } - 15 City/Town h! l'! CP 0 <br /> Owner's Name L ,r> It, L)c i►. 1f•..r �• Phone <br /> Address �. iiiivQ -k • .. City "`- <br /> Contractor's NameL Z) �' ' License# Ul�usiness Phone y In – f_��v� <br /> Contractor's Address r ' Emergency Phone +^ p <br /> Is Certificate of Workman's Compensation Insurance on FIle With SJLHD? Yes 1'`� No <br /> TYPE OF WORk (CHECK): NEW WELL K DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 71 PUMP REPAIR❑ uC <br /> i REPLACEMENT❑ / { <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �IQ Pit Privy _-_ - - 04 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 42 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ;e <br /> JS <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation re <br /> gDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -fin <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing lit <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Ce-w p✓r- <br /> ' ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By ---�"��` �7f-' v yn <br /> PUMP INSTALLATION: Contractor PW C <br /> Type of Pump H P 2 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> c <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 /> Homeowner 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, I shall employ persons subject to workman's compensation laws of California." <br /> I or a Grout Inspection prior to grouti and a at inspection. <br /> Signed X. itle: Date: —z o <br /> (Draw Plot Plan on Reverse Side) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> �'ssw� /,0//o"Ajl Ins <br /> Inspection By� Date Inspection By � c' Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> / DATE DATE p REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 - <br /> Rarnint No - Permit No. Dae Mailed Delivered <br />