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ppllcaIonsWill BeProcessedWhen Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) st– <br /> /ENVIRONMENTAL HEALTH PERMIT -POAW&WELL <br /> (COMPLETE IN TRIPLICATE) /ti!r` �d�JUaWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is t <br /> made in compliance with an Joaquin Countlfrdin ce No. 186 nd the r Ills antregyJ io f the San aquin Local Heal tract. 1 <br /> Exact Site Address / f�� � � � <br /> � Q y/Town <br /> Owner's Name 00 <br /> Address � .� Phone <br /> City G a <br /> Contractor's Name License l 1 <br /> Business Phone p C <br /> Contractor's Address Emergency Phone � C'�44%L, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL A�.DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ -cPUMP REPAIR❑ <br /> • 4 <br /> DISTANCE TO NEAREST: Septic Tank/0Sewer Lines <br /> Pit Privy <br /> -a Sewage Disposal Field Cesspool/Seepage Pit " <br /> Other <br /> Property Line Private Domestic Well `—� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLl << A <br /> �DOMESTIC/PRIVATE Dia. of Well Excavation <br /> ❑ DRILLED –1 <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION . .h. ❑ Gf37tVEL PAGK <br /> El CATHODIC PROTECTION 0'ROTARY Type <br /> of Grout S/P�I�,,� <br /> ❑ DISPOSAL Type of Grout �11r•tDN/ 7` •,t,_. <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By , [ <br /> PUMP INSTALLATION: Contractor <br /> , <br /> Type of Pump H.P. <br /> y <br /> PUMP REPLACEMENT: 11 State Work Done <br /> PUMP REPAIR: E3 State Work Done, <br />—DESTRUCTION OF WELL: <br /> 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 /> 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 ndt 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'fhe•following:"I certify that in the performance of the work for which this <br /> :I <br /> permit Is issued, I shall employ ersons subject to workman's compensation laws of California." I <br /> ill call for a Gro t I do prio to routing and a final inspection. <br /> Signed k. Title: <br /> (Draw Plot Plan on Reverse Side) Date: <br /> FOR PARTMENT USE ONLY <br /> PHASE ' <br /> Application Accepted By <br /> Additional Comments: II <br /> Phase 11 GroutInspectionJ Y Waw -Q_ <br /> Inspection By DatePhasp III Final Inspection , � <br /> Inspection By Date 2 '7i 6 <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 REMITTANCE $ REMIT <br /> DATE DATE? REMITTED AMOUNT DUE CHECKED <br /> FEE ° JAMOUNT <br /> LESS <br /> C/ <br /> `j- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R ceive 6y s - �P- U Receipt NOY No. Is uanc Date MailedAPPLICANT—RETURN ALL COPIES TO: ENYIRONMENTA!HEALTH PERMIT/SERVICES Delive N <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />