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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: I APPLICATION , <br /> (For Non-Transferable, Revocable,Suspendable) <br /> punnP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) f&- WATER QUALITY <br /> 7Z-7 S- <br /> 14� c: -nzn l <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is .� <br /> made in compliance with San Joaquin County Ordinace No. 1862 and the rules and regulations of the San Joaquin Local Health District. d <br /> Exact Site Address Lo U I t �(� OWL.. City/Town !V <br /> Owner's me ©CC E <br /> Phone R <br /> Address - City �` o PC 4L 1 O N <br /> Contractor's Name1�KL-6 +f�FF1-61 - S S License# Business Phone <br /> Contractor's Address Emergency Phone <br /> X <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No — <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.pf OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br />,�_pISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit rOther <br /> Property Line Private Domestic Well Public Domestic Well / - w <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 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION El' ROTARY Type of Grout _ fULG6�T C�r1^FN <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1 <br /> &E&-HY!5+GAL Eo 1 ci I�.t IC,,a� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pump <br /> H.P. <br /> V1 <br /> t PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: <br /> 0 State Work Done TM <br /> DESTRUCTION OF WELL: P Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County 5 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Ib I <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 /> I( Conlraclor'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 for a Grout Inspection prior to routing and a final inspection. <br /> i <br /> Signed X fZ T Title: Date: Z��"������Q <br /> (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br />�. PHASE I r <br /> Application Accepted By Date "S'� � <br /> Additional Comments: <br /> Phase II Grout Inspection ase III Final Inspection <br /> Inspection By pppppp 1(( Date Inspection B J Date <br /> Fee Is Due: ❑ 'ANNUALLY ❑ PE t)NIT ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT <br /> I EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE <br /> t DATE DATE REMITTED AMOUNT <br /> �. FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t - j <br /> OTHER <br /> OTHER <br /> f <br /> I; Received-by Date Receipi No. Permit No. Is uance ate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />