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- T Applications Will Be Processed When Submitted Propeny %,ulll <br /> APPLICATION —aS <br /> rI -fICE USE: (For Non-Transferable, Revocable,Suspendable) pl1Mp&WELL <br /> ,ENVIRONMENTAL HEALTH PERMIT i <br /> TER QUALITY <br /> (COMPLETE IN TRIPLICATE) "1 -J 7']. S " <br /> I ication is hereby made to the San 7oaqui n Local Health District for r a permit to construct and/or instal l the work herein described.This appiication Is <br /> APP vr> �' <br /> made in compliance with San Joaquin County Ordinarice 2K 86��d the rules and regulati City/Towns of the son Jpaquin Loca4 Health District. i <br /> oll— <br /> Exact Site Address/{ /� / I f rL� / /�' T hon <br /> r <br /> Owner's Name <br /> Address i -- Business Phone <br /> ti Jy License# <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation:insurance on File With SJLHD? Yes LL DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> ` TYPE OF WORK (CHECK): NEW WE ❑ PUMP REPAIR❑ <br /> f WELL CHLORINATION 11 WELL. ABPUMP INSTALLATION <br /> $Z <br /> ❑ OTHER <br /> REPLACEMENT❑ Sewer Lines Pit Privy r-Z3��a �� Al( <br /> ` DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well -- <br /> Property Line ✓�'f Private Domestic Well ;! <br /> TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL <br /> ❑-CABLE TOOL pia. of Well Casing <br /> - � pRILLED /} <br /> 11DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing `~ <br /> ❑ DOMESTIC/PUBLIC 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATIONType of Grout <br /> e � <br /> t ❑ CATHODIC PROTECTI ❑ ROTARY ON Other Information <br /> t. W� <br /> 11C1 OTHER DISPOSAL Surface Seal installed By: <br /> J@6,-- «`I <br /> PUMP INSTALLATION: Contractor ".P. <br /> of Pump <br /> h � <br /> ❑ .State Work Done <br /> PUMP REPLACEMENT: X State Work Done <br /> PUMP REPAIR: A imate De tfz <br /> eWell Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> n County <br /> I hereby certify that I have prepared this applica ion and that the work wi1I be a in accordance with San Joa <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 w <br /> hich this permit <br /> an person in such manner as to become subject to workman's compensation laws of California." <br /> is issued, I shall not employ y P I certif that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the following:` Y <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I will call for a Grout Inspection prior to grouting and a final inspecho V Date: <br /> Title: <br /> Signed )C �� <br /> (Draw Plot Plan on Reverse ide) <br /> ilr <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i u Date <br /> i Application Accepted By <br /> Additional Comments: Ph III Final Inspection 3 0 <br /> A Phase II Grout Inspection Ins e <br /> inspection By <br /> D to /$�`' <br /> {' ❑ January 1 Received By January 31 July t &Received By Ju' IyU1 <br /> ` REMIT <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH REMITTANCE $ AMOLSNT DUE CHECKED <br /> BILLiNG DATE REMITTED AMOUNT <br /> RASE EXPLANATION DATE <br /> S <br /> FEE t{[( <br /> LESS yi <br /> PRORATION <br /> G PLUS <br /> PENALTY f <br /> OTHER € <br /> OTHER f <br /> Issuance Date Mailed Delivered <br /> Receipt No. Permit No. STOCKTON,CA 95201 <br /> Received by - Date 1601 E.HA7FLTON AVE.,P.o.Box 2009 <br /> ' pPpLIGANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' <br /> ��,I' �- <br />