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Applications Will Be Processed When Submitted Properly Completed. Be Sure To sti�h ilkpjA1cafiok': * `- UUi <br /> ,FOR OFFICE USE: APPLICATION <br /> -c�� 98� <br /> (For Non-Transferable, Revocable,Suspendable) PUHA 1�E1_I <br /> ENVIRONMENTAL-HEALTH'PERMIT l <br /> WATER;QUALITY 1 �� ifi rrt <br /> (COMPLETE IN TRIPLICATE) ..,, .." � . _• ��� f �'.�,..��-..,,"v I <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 1�g/62 and the rules and regulations of the San Joaquin LocW Health District. <br /> Exact Site Address_1J11/16 City/Town 703 <br /> Owner's Name Phone 6- + <br /> Address y .� :� �t'ar. City <br /> Contractor's Name �.Sd '� License G - ` Business Phone!' <br /> Contractor's Address ��+ ' r "' .'Emergency Phone -4 - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—fes— No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑LL DESTRUCTION❑.. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT% <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal.Field .Cesspool/Seepage Pit Other- <br /> Property Line Private Domestic Well Public Domestic Well_ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> .91 DOMESTIC/PRIVATE ❑ DRILLED „ Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC., ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> 13 DISPOSAL V <br /> ❑ GEOPHYSICAL r Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done L11 <br /> PUMP REPAIR: ❑ State Work Done - �... u, <br /> DESTRUCTION OF WELL: Well Diameter 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:1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." 4 <br /> 1 <br /> I w' II for a Grout�nption rlor to grouting and a final inspeciio r <br /> Signed X _ Title: - Date::=.� <br /> (Draw Plot Plan on Reverse Side) '' a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> V Oti;�, ` � Date a <br /> Additional Comments: <br /> Phase II Grout Inspection R Phase III Final Inspection <br /> Inspection By Date Inspection By Date 7-3 - , <br /> Fee Is Due: ClANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH' ❑ January 4 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> y DATE DATE REMITTEE AMOUNT <br /> FEE �r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER h - <br /> OTHER 7 .. . <br /> 7!mi AT _ <br /> Received by ­ D to I Receipt No., - Permit No, Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HIE LTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,GA 95291 <br /> k"' - - <br />