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wa Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic�atilo ` <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) kz a 4" <br /> AmWELL <br /> rhiviRONMENTAL HEALTH PERMIT / <br /> //"� WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Cf�[ 15 ( /�E�G Q( J — f`-(o —(�� . <br /> Application is hereby made to the San Joaqui n Local Health District fora permit to construct and/ort s all the work eln described.This app Icatian is <br /> made in compliance ith San Joaquin County,t/Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address !I ;� AffiI 14!S' to rp �`��p+t' City/Town <br /> Owner's Name �C�iz r <br /> +- fir' a" Phone <br /> Address S - ,It alacrr C 4,4 e f City r ,a✓ <br /> Contractor's Name r _ License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A--"" No }I,! <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONt ' PUMP REPAIR❑ <br /> REPLACEMENT❑ . <br /> DISTANCE TO NEAREST: Septic Tank +* i * 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 r Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE' ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> iGATION 11 GRAVEL PACK Depth of Grout Seal <br /> LJ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a ' ` <br /> Type of Pump � .; <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f 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 /> 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 /> *t Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work torwhich this <br /> permit is issued, I shall,employ persons subject to workman's compensation laws of California." <br /> #" 1 will call for a Gro spection prior to grouting and a final inspec •on. <br /> Signed X r Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r � <br /> Appl$ation Accepted By f ' r—"�� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> ,. Inspection By Date Inspection By Date <br /> Fee IS DUB: ❑ ANNUALLY PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuVy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS- <br /> i PRORATION _ <br /> .- s.P.LUS.[PENALTY <br /> OTHER <br /> OTHER <br /> -761 i' <br /> _•,W Received by Date Receipt No Permit No. Issdancd 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 />