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Applications Will Be Processed When Submitted ProperlyL:ompebs--� , P <br /> APPLICATIO ELL <br /> FOR OFFICE USE: (For Non-Transferable, Revocable, + <br /> NTAL HEALTM T 2 19a� <br /> ENVIRONMENTAL <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) TTi�ss <br /> d the rules and regulaha�9ulli cal Health District. <br /> Application <br /> / Kkns 1� 1^Ic h lrn l Healt.Thi trio.cation is <br /> pP 1� <br /> made in compliance with San Joaquin C unty Ordinance No.186 i y own <br /> Exact Site Address phone -261 ,V- ,73 L <br /> � � 1 <br /> Owner's Name City . s <br /> Address // 3 Business Phone <br /> License#/b <br /> Contractor's Name Emergency Phone 1 <br /> Contractor's AddressNo -J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> 13 ESTRUCTIONO <br /> TYPE OF WORK (CHECK): NEW WELL MENT ❑DEEPEN ❑ OTHER 13 RECONDITIONPMP INSTAL ATION ❑ PUMP REPAIR <br /> WELL CHLORINATION 11 WELL ABANDON <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> Dia. of Well Excavation <br /> 13 INDUSTRIAL El CABLE TOOL❑ DRILLED Dia. of Well Casing <br /> 13DOMESTIC/PRIVATE 13 DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC 13GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> 11 State Work Done -- <br /> PUMP REPLACEMENT: L7 State Work Done <br /> PUMP REPAIR: :t�Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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. r which this <br /> ce of the Home owner or licensed agent, signatures certifies such mhe following: <br /> in become subject that i to the <br /> perfor nos compensa�rk onoaws of Californ alt <br /> is issued, I shall not employ y person <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fvrwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." o <br /> I will call for a Grout Inspection prior to grouting and a final inspection. Date: <br /> Title: &-7 <br /> Signed X (Draw Plot Plan on Reverse Si ) <br /> FOR DEPARTMENT USE ONLY q� J <br /> PHASE I ems, Date <br /> r <br /> Application Accepted By <br /> Additional Comments: Final In ection 9 Z <br /> Phase II Grout inspection inspection By �y ate J <br /> Inspection By Date <br /> REMIT <br /> ❑ PER SITE ❑ EACJanuary 1 &Received By January 31 July 1 8 ReceiCµ <br /> By July 31 <br /> Fee Is Due: ❑ ANNUALLY C1 PER UNIT EMIT <br /> -BILLING REMITTANCE $ AMOUNT DUE AMOUNT <br /> CKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �511 <br /> " Receipt N. Permit No. <br /> Issuance ate Mailed Delivered <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />