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Applications Will Be Processed When Submitted Properly Completed. Be S W oAg)�WApplication U, <br /> FOR OFFICE USE: APPLICATION qa� <br /> (For Non-Transferable, Revocable, Suspendable APPp�&`91,L <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN t-OCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -AIH DISTRICT <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install th rk erein described.This application is <br /> made in compliance with Sial oaquin County Ordinance No. <br /> 11/662 and the rules and regulations of the San oaquin oocal Health District. <br /> Exact Site Address .2 / 17 �. {�r<fc-�. J) _ City/Townp�p�[_^�L�.fy���✓ <br /> Owner's Name Phone D. r 02 y/ <br /> Address ryC City �� �� <br /> Contractor's Name n.. ?✓ License� 1/d/Q _ Business Phone PJI9 o2. L77 _- <br /> Contractor's Address �c /, Emergency Phone 314 & t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No L <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Gj <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 Wel[ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL -. ❑ CABLE TOOL Dia. of Well Excavation <br /> 56 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <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: ® State Work Done 7- <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 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 certify that in the performance of the work forwhich this V, <br /> :permit is issued, I shall employ persons subject to workman's compensation laws of California." - <br /> I will I fora Grout pe ion prior to grouting and a final inspectlp . <br /> Signed XTitle: TS Date: 3 <br /> (Draw Plot Plan on Re erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI b <br /> Application Accepted By Date <br /> Additional Comments: ' <br /> Phase II Grout Inspection ahtaseI Final Inspectio <br /> Inspection By Date Inspection Date <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE q,5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - Received by bate 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 />