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FOH OFFICE USE: APPLICATION <br /> + (For q+lon-Transferable;=Rerov;ab{e, Suspendatil <br /> ENVIRONMENTAL HEAL I:PERMIT <br /> .,< _ <br /> � (COMPLETE IN TRIPLICATE) � „ <br /> ,:. llYiilTER QUALITY '-. . �� .��/ Pp <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or inata�ll the W <br /> edlis a lication is <br /> made in compliance wit qjn oa t r�pance No. 1862 and the`rules and regulations of 1#i9ttn Joaquin Oat Health District. <br /> I Exact Site Address ` q10 1 <br /> cityl�'own.;� -9 Py/K4 <br /> .,Owner's Name 9'.� <br /> Address rj' Phonli __ <br /> City_ F.. r�r <br /> Contractor's Name t.:icense-# gu9jfle�>tfht?fje 1 <br /> Contractors Address Emergency.Phone 1/6 S O� ` <br /> ls,Certificate of Workman's:Compensation'insurance on File With SJLHD9. Yes es No <br /> ` <br /> '"'TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITI.ONO DESTFIUCTION❑ <br /> WE'Ll:"CHLORINATION 13 <br /> REPLACEMENT❑ WELL'AEIANDONMENT❑ OTHER ❑ ?=PUMP'WSTALLATION Q PUMP REPAIR ice. <br /> - _ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> opertyLine --Private Domestic.Well Public Domestic Well <br /> INTENDED USE "Z'" . TYPE OF Wt <br /> ❑ INDUSTRIAL ❑-CABIN TOOL; Dia-'"'Well Excavation.,; <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK " ?Depth of Grout.Sdal <br /> ❑:.CATHODIC PROTECTION ❑.ROTARY ,Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information-- <br /> ❑ GEOPHYSICAL Surface-Seal Installed <br /> ::.PUMP INSTALLATION: Contractor <br /> :. .. T,ype:of Pump _ ..... l <br /> :PUMP.REPLACEMENT'>":._ fl'State Work Done <br /> PUMP REPAIR: 19 StateWork Done <br /> . DESTRIICIF4 N QF-WEL .. Weil Diameter _u 'Approxijnate Dep,Yh <br /> Describe-Material and Procedure <br /> I hereby c0tffy.1hat.I;have prepared this application and-that-the work-will be dotill 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 lulrformance(it 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 sub-taf#OW#gg,slgaatiue certifies the following,"I certify that In the performance of the work forwhich this <br /> permit is issued, I shall employ persdrit' t bject to,workman's compensation laws-04 California:'; <br /> 1 will call for a Grout Inspection prior to grouting ainc#aainalnspection: <br /> Signed X "Date: d t7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D PARTME -U Oh1LY <br /> PHASE I <br /> •- <br /> Application Accepted By pate <br /> Additional Comments: <br /> Phase 11 GroutAnspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Is DLw.❑:ANNUALLY ElPER UNIT ❑ PER SITE ❑ EACH ❑.yartua y I &Received By January 31 C1July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMlTIANGE 3Y4 REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered,- <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />