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Applications Will Be Processed When Submitted Properly Complete+ll. SureToSignTheApp1ca1 <br /> FORFFiCE USE: <br /> APPLICATION JAN 14 1980 <br /> . <br /> I 'f (For Nan-Tranlerabte, Revocable, Suspendable) p jV1p&WELL <br /> ENVIRONMENTAL HEALTH PERNI�AN ,JOAQUIN L.CZR 0i <br /> LTH Dl5TI�lc,T a ! <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEA2--o Q- � <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is gy <br /> made in compliance w t San Joaquin u ty Or finance,Np. 1862 and^ rules and egg ions of n Joaquin Local Health Distr'ct. <br /> Exact Site Address ", ✓ �/ o <br /> "Y - <br /> Phone <br /> Owner's Name . <br /> Address City - <br /> Contractor's Name License# 9n Business Phone <br /> Contractor's Address Emergency Phone 7/ <br /> Is Certificate of Workman's Compensation o <br /> Insu nce on File With SJLHD? Yes Jr'/ No <br /> TYPE OF WORK (CHECK): NEW WELL V DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER'❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line Pit Privy <br /> v -Sewage Disposal Field L Cesspooi/Seepage Pit Other <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11CABLE TOOL + -� - --Dia:of Well-Excavation <br /> / <br /> M DOMESTIC/PRIVATE ❑ DRILLED E Dia. of Well Casing <br /> MDRIVEN ! Gauge of Casing / <br /> ❑ DOMESTIC/PUBLIC 1GlJJ <br /> ,_❑1,,� f <br /> 11 %IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 141"90TARY Type of Grout <br /> ❑ DISPOSAL` <br /> 11 OTHER Information <br /> OTHER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: v <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> PUMP REPL-AGEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure : <br /> ~: <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 /> r Home owner or licensed agent's signature certifies the following:"I certify that in the performance of 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-contracting signature certifies the following:"I ce ftify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensate laws of California." <br /> Irw' caN fora out pection prior to grou' and a final inspection. <br /> -Title:_ <br /> -. <br /> Date: <br /> Signed X, <br /> I (Draw Plot n on Reverse Side) <br /> 1 <br /> FO DEPARTMENT USE ONLY <br /> PHASE t <br /> Date <br /> Application Accepted By <br /> �- <br /> f Additional-Comments: <br /> r x _ Phase II Grout Inspection r hase I Fin pection <br /> 7 --Date• - ---Inspection Sy -- Daie- <br /> —.-Inspection-By- <br /> Fee Is Due: 13 ANNUALLY'\ PER UNIT C1 PER SITE ❑ EACH ❑ January 1 &Re ived By January 31 ❑ July 1 &Received By Jury 31 <br /> REMIT <br /> , BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> T DATE..f, - a DATE REMITTED, y AMOUNT <br /> FEE <br /> LESS <br /> k PRORATION <br /> PLUS _ <br /> i PENALTY <br /> r OTHER <br /> OTHER <br /> b � . <br /> Permit No. Issuance Date Mailed Delivered <br /> Received by ate Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: '�ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Bol 2009 STOGKTON,CA 95 <br />