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Applications Will Be Processed When Submitted Properly Completed. r id&Ttb AVpli io f <br /> ICOR OFFICE USE: APPLICATION U <br /> (For Non-Transferable, Revocable,Suspen ) JAN 2 TLUt"M9P w <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ..WATER QUALITY � SAM,i0AQUiN LOCAL <br /> Application is hereby made totheSanJoaquin Local Health District for apermit toconstruct and/orinsW&AJrTr QW& Tbed.Thisapplicationis <br /> made in compliance wit Sa Joaquin County Ordinance No. 1862 and the rules and regulations-6f the San Joaquin Local Health District. <br /> Exact Site Address �� City/Town 'IS <br /> f06C" AW <br /> Owner's Name -' - ',C 7. Zr y E Phone rr <br /> Address S" "t `Ys w - i:;- City Ga <br /> Contractor's Name s �"s r� rj t7A'-� License# i+�/ - `Business Phone, 4:2.20-� <br /> Contractor's Address a7O0 Emergency Phone ` < -e_--- <br /> { Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):._ NEW WELL❑ DEEPEN D RECONDITION 13DESTRUCTION NO " <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> I" REPLACEMENTI� s <br /> �-_DISTANCE,TO NEAREST: ­Septic - .:,P,..�--•Sewer Lines4p- - -==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 Y ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 /> ❑ DISPOSAL El OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: , Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State-Work Doner�lat� <br /> PUMP REPAIR: ❑ State Work Done <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:"I certify that in the performance of the work for which this permit <br /> =is issued, l 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 workmar's'compensation laws of California." <br /> I WP-call for a Grout spectiotn prior to grouting and a final inspection, <br /> f Signed X Tiile: . Date: <br /> (Draw Plot Plan on Reverse Side) A <br /> OR D PARTT USE ONLY <br /> i PHASE <br /> i <br /> 4�EN <br /> / / <br /> Application Accepted By <br /> Date - <br /> Additional Comments:` <br /> Phase II Grout Inspection R Phase III Final Inspection <br /> Inspection By Date Inspection By J- +---( Date <br /> 5 <br /> Fee Is Due: ❑ ANNUALLY '- ❑:PFR UNIT': - ❑ PER SITE EACH "' ❑'Jarivaryl &Received By January 31 '' ❑'Juiy 1 &Received By July 31 <br /> w BILLING REMITTANCE $ REMIT <br /> " BASE ' EXPLANATION ��.. ^'; -AMOUNT DUE CHECKED <br /> ' DATE DATE REMITTFD.� AMOUNT <br /> FEES <br /> LESS + <br /> PRORATION a ' <br /> PLUS <br /> PENALTY <br /> OTHER _ :fir, e , <br /> OTHER Y <br /> ;C7 � 6 �y <br /> Received by Date- Receipt No. Permit No. - Issuance Date- Mailed - Delivered --- <br /> APPLICANT--RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA_ZELTON AVE.P.O.Box 2009 STOCKTON,CA 95201 <br />