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The IA �IIicatiQIn --- s / <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure T �1 itl [ 7700 <br /> FQft OFFICE USE: APPLICATION l iV <br /> (For Non-Transferable,Revocable, Suspendable) P'f, �t) 4L <br /> SAS �.,.",iCC�'.AL <br /> jV l- <br /> ENVIRONMENTAL-HEALTH PERMIT HEALTH DISTRIC'T <br /> WATER QUALITY , , <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> - City/Town <br /> Exact Site Address <br /> _ L1_ Phone <br /> Owner% Name yl j City <br /> -5.4 M� P ' "o2a <br /> -7Address License#279060siness hone10 <br /> Contractor's Name iA <br /> Contractor's Address _. ��' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):'—NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ I <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR® <br /> REPLACEMENT❑ <br /> ' Sewer Lines Pit Privy ..� <br /> DISTANCE TO NEAREST: Septic Tank _ _ <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 /> ` <br /> ElDRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: {� <br /> PUMP INSTALLATION: Contractor /Y <br /> H P <br /> Type of Pump } <br /> PUMP REPLACEMENT: - ❑ State Work Done Ac i <br /> (� <br /> PUMP REPAIR: -14 State Work Done <br /> Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: _ <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will l for a ro����7lan <br /> final inspecti ' <br /> Signed X <br /> Title: ' Date: <br /> ( raon Re erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ©� Date ` <br /> Application Accepted By <br /> Additional Comments: <br /> se 11 Grout Inspection Phase 111 Final Inspectlon� <br /> Inspection By Date Inspection Byr <br /> Cic�—�---- Date A <br /> d By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH El January 1 &Received By Januar 1 ❑ July 1 &Receiv RE IT <br /> 31 <br /> ON BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> sFEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ` Issuance Date Mailed Delivered - <br /> Received by to Receipt No. Per No.- <br /> 7601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES , <br />