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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignVskPL20182 FOR OFFICE USE: ' APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)"1(P-772 S 44ck,) ,AM WATER QUALITY k414� r, SAI` JOAQUIN LOCAL <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/or install the work here11W9&11M,.W1S1PXp1QTion is <br /> made in compliance with San Joaquin County Ordi once No. 1862 and the ules and regulations of the San Jo in Local Health District. <br /> Exact Site Address -3' City/Town <br /> Owner's Name 6eC' 'e C 4 �- Phone." + � �� <br /> Address <br /> Ity. <br /> R ' usiness Phone <br /> Contractor's Name License#PIZ,%Contractor's Address T' `" EmercyP <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No (] <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El " RECONDITION❑ DESTRUCTION❑ a C/ a <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 -f TYPE OF WELL <br /> INDUSTRIAL �R" 4r/ate ❑ CABLE TOOL, Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.bf Well Casing <br /> I fi <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ,F ol3 <br /> i� J"h. 011 1Y <br /> ❑ IRRIGATION El GRAVEL PACK Depth of Grout Sea] d <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1:1 GEOPHYSICAL Surface Seal Installed By: V <br /> PUMP INSTALLATION: Contractor <br /> a Type of Pump N.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 far 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." <br /> I will call for Grout In ection prior 10 grouting and a final inspection. <br /> Sign d XTitle: Ni• ' ... Date: d + <br /> (Draw Plot Plan on reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '- <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> L <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 8 Received By Ju4y 31 <br /> REMIT <br /> I BILLING REMITTANCE $. AMOUNT DUE CHECKED <br /> BASE `EXPLANATION DATE DATE REMITTED AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � 3 � / 335 <br /> Received by I Date. Receipt No., .Permit No. - - Issuance Date Mailed Delivered <br /> y APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />