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Applications Will Be Processed When Submitted Properly Completed. Be Sure T4SW rIJe4WtdaMn.V JJ 1 <br /> FOR OFFICE USE: tie _ APPLICATION UH # <br /> (For Non-Transferable, Revocable, Suspendable) 7 <br /> ..IUL UJWELI_ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SAN JCIAQUiN LOCAL ' <br /> (COMPLETE IN TRIPLICATE) ��1�VP PItPRJUpp <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the wor r esc I d. I Iicati in is <br /> made in compliance wi4tiSnJoNquinourtty Qfdinance No. 18fi2 and the rules and regulations of the 5 o0agtair LOoal Health District. <br /> Exact Site Address I ae one City/Town <br /> ,ka e>!' ezc <br /> Owner's NamePhone <br /> Address • City <br /> Contractor's Name Lionecense# Business Phone-62 1422 <br /> Contractor's Address !i Emergency Picone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN C1RECONDITION ClDESTRUCTION❑ .,_�.�_m _ Yt <br /> WELL CHLORINATIONI❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION © PUMP REPAIRQ Q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 4 <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other �A <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOME_STICIPRIVJW ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing y <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout F <br /> ❑ OTHER Other Information <br /> 11 DISPOSAL r- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. HPt <br /> PUMP REPLACEMENT ❑ State Work Done ' <br /> PUMP REPAIR: I `Stat"e Work-Dane —_ _._ _ __ •—JY-- _. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> H 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 1 <br /> ordinances,!�state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> 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 cat r a Grout Inspe nor to gro. Ing and a final inspection. <br /> Signed X _ <br /> Title: - Date: 6 r 3o �� 1 <br /> f (Draw Plot Pian an Reverse Si e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i ._.. <br /> Application Accepted By eR- �!� Dat ��B�B�. <br /> Additional Comments: <br /> I�. Phase It Grout Inspection Pha II Fin Inspection <br /> Inspection By Date inspection y F <br /> 'ter <br /> IN -- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PEO SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> ' <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE -'DATE REMITTED AMOUNT I <br /> FEE5�� —� <br />�. LESS <br /> PRORATION <br /> PLUS <br /> PENALTY } <br /> OTHER <br /> 1 <br /> 'OTHER <br /> 7 � <br /> " �'.rd by �� Dace Receipt No. _ Permit No. - issuance Date- Mailed De4ivered <br /> �PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELToN AVE.,P.O.Box 20D9 .STOCKTON,CA 95201 '"�' <br />