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Applications Will Be Processed When Submitted Properly Completed. Be Surei n'fQpJ&A& V � UU <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) J U L �UMWBQ ELL <br /> �f11 <br /> riT ENVIRONMENTAL HEALTH PERMIT . <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL, <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the worki birTRs&)i6$J.%a�pplica on is <br /> made in compliance with San Joaquin County Ordinance o. 1862 and the rules ay regulations of the SIV <br /> O I al Health District. <br /> Exact Site Address <br /> Ban R. McGeehee , 1.763 S. Harmony Ln City/Town d � <br /> Owner's Name Phone <br /> Address 1761 . Har-f� City <br /> tockton <br /> Contractor's Name Ma(- +ado- Ir t- License#377040 Business Phone 462-1424 <br /> Contractor's Address Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <br /> t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing _ <br /> .+� <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information v <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump — H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: d State Work Done I <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 /> 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 si ature certifies the following:"l certify that in the performance of the work for which this 3 <br /> permit is issued, I shall empl persons ubject to rkman's compensation laws of California." <br /> ,F ill all for a Gro t I spe n prior grouting n a final inspection. <br /> Signed tIe V s Pr e S. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By `7�G ,C�r�/9� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [] July 1 &Received By July 31 <br /> REMIT 11 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER R <br /> OTHER <br /> t 06 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> l <br />