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FOFi OFFICE USE: ,�^ APPL[CATION <br /> r <br /> f ;or Non-Transferable, Revocable,S d` ej 10j�g <br /> ENVIRONMENTAL HEALTH IT �)G O�PAaP&WELL <br /> (COMPLETE IN TRIPLICATE) warEii QUALITY <br /> ON <br /> Application is hereby made tothe San Joaquin LocalHealthDistrictfor apermit toconstruct and/or i hL0 A �1S <br /> made in compliance with San Joaquin County Ordinance No. 1862 annd�he rules and regulations � �herein described.This application is <br /> Exact Site Address_f% Z No�rl 9 l an Jo�puin Local Health District. <br /> City/Town K <br /> Owner's Name <br /> Address Phone S <br /> Contractor's Name ,-� City <br /> Contractor's Address License# q�� <br /> ,. � - Business Phone <br /> Is Certificate of Workman's Compensation Insurance on Ile With SJLHD? <br /> Emergency <br /> Phone <br /> No <br /> TYPE OF WORT( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ UMP IN TALLATION <br /> REPLACEMENTH P REPAIR❑ r_- <br /> f DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field CesspoollSeepage Pit n <br /> Property Line Other J <br /> p y Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑' INDUSTRIAL ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE Dia, of Weil Excavation <br /> 11DOMESTIC/PUBLIC ❑ DRILLED Dia. Of Well Casing <br /> ❑ DRIVEN Gauge of Casing Q <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> ❑ CATHODIC PROTECTION 13 ROTARY Depth of Grout Seal <br /> E) DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOP Y <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor AZ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; J9 State Work Done <br /> PUMP REPAIR. ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> - �_.•-P Oma__ � ^ � . <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 orsub-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 will call for a Gr ut Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: _ -- — <br /> {Draw Plat plan on Reverse Ide} <br /> F DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Dat <br /> Phase II Grout Inspection <br /> Inspection ByP Final I pection <br /> Date Inspection B A <br /> Date _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1&Received'By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION ' BILLING REMITTANCEL REMIT <br /> �I DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ��/ ' AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date -79— �•3a 7 Iq <br /> Receipt No. Permit No. Issuance Date <br /> APPLFCAMT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES� � Mailed Delivere <br /> 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />