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Applications Will Be Processed When SubmittedProperly L;omplelea. oeoure IV �y •� rr••�- <br /> FOR alicE USE. APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pLiMP&WELL, <br /> ENVIRONMENTAL HEALTH PERMIT 0 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health Di trict. <br /> Exact Site Address <br /> Gdc[lsC' �/�14�lk��c �vlAru-Tey City/Townf11'�'z3 u� <br /> LL �•/ /� <br /> Owner's Namejydo <br /> Address City <br /> dx yam` <br /> Contractor's Name 14H, <'��?�` �iSSaG. License# Business Phone 3 S <br /> Contractor's Address 5 eve " Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes <br /> TYPE OF WORK(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION 13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 9( 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 Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL rJ114 <br /> 13INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation /104 <br /> ❑ 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 11 ROTARY Type of Grout ��¢ Ce"1 ` !` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surf c Seal Installed By: V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL:' Well Diameter Approxi epth J�4AI <br /> Describe Material and Procedureazo <br /> her certify th ihave prepared this application a that the work will be done i accorda ce with San Joaquin my <br /> ordinance�aws, 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call <br /> for a,Grout Inspection prior to grousing and a final inspection. <br /> • i_ Date: <br /> Title: <br /> Signed X <br /> y � (Draw Plot Plan on Rever a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date �. <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection 0 <br /> Inspection By Date Inspection By 3rate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Jany 31 ❑ July 1 &Recei ed Bly•37 <br /> REMIT <br /> BASE EXPLANATION BILLING OEMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. <br /> Permit No. � Issuance Date Mailed Delivered " <br /> APPLICANT—RETURN ALL CONIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />