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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign TheApplication- <br /> I_oR OFFJCE USE: APPLICATION ,. <br /> (For Non-Transferable, Revocable, Suspendable) P&WELL <br /> ENVIRONMENTAL HEALTH•PERMIT r rf <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY { -. ,T <br /> Application is hereby made tothe San Joaquin Local Health District for a"permitto construct and/or install thework;herein.described.This application"is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San_J uin Local Health District. <br /> Exact Site Address B2 7 7f h ey _ City/Town c2 <br /> Owner's Name ' Phone ' ' <br /> City` <br /> Address E <br /> i Business Phone 7 2 S <br /> Contractor's Name License# °` <br /> Contractor's Address t+� Emergency Phone �y4 6Q�2► <br /> Is Certificate of Workman's Compensation Irance on File With SJLHD? Yes - y No <br /> TYPE OF WORK (CH5CK): NEW WELL ns DEEPEN ❑ ' RECONDITION❑ DESTRUCTION V <br /> Q> <br /> WELL CHLORINATION ❑ r -WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ -PUMP REPAIR O_ I <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tanki Sewer Lines Pit Privy , <br /> Sewage Dispos��aal Fi�ld /7S Cesspool/Seepage Pit Other i <br /> Property Line Private Domestic Well Public Domestic'Well <br /> F INTENDED USE TYPE OF WELL �s <br /> C] INDUSTRIAL ,*CABLE TOOL Dia. of Well Excavation <br /> I�DOMESTIC/PRIVATE ❑ DRILLED Dia.'of Well Casing ! <br /> ❑ DRIVEN Gauge of Casing <br /> f ❑ DOMESTIC/PUBLIC <br /> ❑ IRRIGATION -- ❑-GRAVEL-PACKY-.�. - --� Depth of Grout Seal. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY•t! Type of Grout <br /> ❑ DISPOSAL _ten OTHE ' Other Information <br /> ❑ GEOPHYSICAL 4 rf a `fur ace Seal tall By: <br /> PUMP INSTALLATION: Contractor '-- -" - <br /> LL., <br /> Type of Pump - H.P. . <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 1 t <br /> .t" ,' 4 r - 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. 4 <br /> Home owner 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 ceErtify,that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation l s of California." i <br /> a a. <br /> I will c II or a Grout I pection• rior 1oAgr'ouiing and a final inspection. <br /> Title: y l .'Date:, <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> - <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> f h se IIJ•F' sgeciion <br /> P e 11 Grout Inspection f + - <br /> Date f Inspt3ction 8y -� <br /> Inspection By I <br /> "" P1 <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ©"January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> k i REMIT <br /> - <br /> BASE iBILLING "REMITTANCE i $ AMOUNT DUE CHECKED <br /> F "EXPLANATION ! DATE DATE j. REMITTED AMOUNT <br /> FEE' <br /> S ' <br /> LESSF p <br /> PRORATION ` 3 <br /> 3f , <br /> PLUS a Sq t F •� t <br /> PENALTY <br /> OTHER .. { ` <br /> OTHER ` <br /> Received by <br /> ate 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 />