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Applications Will Be Processed When Submitted Property Completed. Be Surenift' c ilio <br /> FOR OFFICE USE: APPLICATION UPM ZZ55 1.1 <br /> (For Nan-Transierable, Revocable, Suspendable) 72 _3 <br /> ENVIRONMENTAL HEALTH PERMIT NOV T�AJ� ELL <br /> 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JQP,0U1N CAL 9� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�lt,fi�rs€I,c}e l� pplicationis <br /> made in compliance with San Joaquin County Ordinance No.18 2 and the rules and regulations of the San Jro�aLquin [LoocaMealth tis rict. <br /> Exact Site Address Q to 6 7 S, h"6A/ -ey AZ City/Town Z <br /> Owner's Name C) • G N/� M tart/ Phone <br /> Address City <br /> _ � <br /> Contractor's Name T �S� U.c rl SiT.C� License#v?zi.11C� Business Phone <br /> Contractor's Address Zo o',3 i12, iirJ Emergency Phone� S.17 10" 2 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA IRC�.' s <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage Disposal Field Cesspool/Seepage Pit Other _ <br /> f <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 ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal y` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Q' <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 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 5 <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 signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ ersons subject to workman's compensation laws of California." <br /> I will call- r Gro��cfion' <br /> grouting and a final inspecti i <br /> Signed X Title: " Date:- —,0, - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTME T USE ONLY <br /> PHASE D <br /> Application Accepted By Date / I <br /> Additional Comments: <br /> Phase II Grout Inspection Phase II Final Ispection <br /> Inspection By Date A� Inspection By i Date a-3--? <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMIT <br /> REMITTANCE $ <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS~ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dalef Receipt No Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009, STOCKTON,CA 95 <br />