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Appli i s iWe�" s n ilted Properly omp e / <br /> OFFICE USE: _'PPLICATION <br /> FOR t j <br /> . on-Transferable, Revocable,Suspendable) <br /> -y'Y ._. �R 23 (�9� I unn�&WELL <br /> =J ENVIRONMENTAL HEALTH PERMIT <br /> F .5'Aii;":,QI HN I:OCAL WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) , i l p <br /> Application is hereby madeto the S Aa n ocal`;T Ft +strictfora permit construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count. Ordinance No. 1862 and the rules and regulations of the San Joaquin Local ealth District. <br /> or City/Town <br /> Exact.5ite Address �� ��0 <br /> Phone <br /> Owner's Name �' e� OU <br /> City <br /> Address i A. Ma.l �yGense# " Business Phone <br /> Contractor's Name <br /> _,� _TC�' Emergency Phone <br /> Contractor's Address ��� �— No <br /> Is Certificate of Workman's Compensation Insurance on File With SJ_LHO? Yes — <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN 11RECONDITION[] DESTRUCTION❑ <br /> ( WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage:D'+sposal Field <br /> GesspooI/Seepage Pit Other <br /> Property'Line S I Private Domestic Well __Rje Public Domestic Well <br /> 1 INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I- 13 DOMESTIC/PUBLIC 13 DRIVEN <br /> Gauge of Casing <br /> 11 IRRIGATION 13 GRAVEL PACK �-- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> i 13OTHER Other Information <br /> 13 DISPOSAL <br /> I Surface Seal installed 8y: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> I H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Q'� Approximate Depth <br /> DESTRUCTION OF WELL: ` <br /> Describe Material and Procedure <br /> I hereby certify that i have preparedhcthat 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 /> 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 certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." F <br /> I will call for a rout spection for torgrouting and a final inspection. r <br /> I �, Title: ' Date: <br /> Signed X <br /> } (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE 1 �Q�10.�, 1� DateWt <br /> Application Accepted By <br /> Additional Comments: <br /> k PPhase til Final Inspection <br /> Phase 11 Grout Inspection <br /> nC� ' ,�C� Date Inspection By Date <br /> Inspection By���-,-'`--g . <br /> Fee Is DUB: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT my 31 <br /> ON BILLING REMITTANCE -$ AMOUNTDUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> + <br /> ly) d3 0 �- <br /> 1 -Dae Receipt No. Permit No. Issuance Date Mailed Delivered- <br /> , Received by - <br /> APPLICANT—RETURN ALL:COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTgN AVE.,P.O.Box 2009 STOCKTON,CA 9520Y <br />