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- Applications Will Be Processed When Submitted Properly Complete G, ulo sign Th�i-AApplication. <br /> F R"�FFICE USE: APPLICATION I <br /> (For Non-Transferable, Revocable, nd4. r� <br /> 'r ENVIRONMENTAL HEALTH I �� "�-1 AAP&WELL <br /> WATER QUALITY )� D�S�� <br /> (COMPLETE IN TRIPLICATE) �173-� r�1: {��. ,,,,pp�N 22� ��(f7- D� <br /> Application isherebymade totheSanJoaquinLocal Heal thDistrict forapermittoconstructand/ot�tslirorkherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of a San Joaquin Local He 4 istrict. <br /> i Exact Site Address _� Sa. �aL;imA/es � City/Town .J <br /> Owner's Name RID /a-- �14Phone "99 s <br /> AddressCity 'e-L'c� <br /> Contractor's Name /f/'.i--� License#3�FS7S Business Phone <br /> Contractor's Address 160, 60,K 91ifcAl fS"4k Emergency Phone S 9if 5!cS-(,- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 ll- <br /> REPLACEMENT I� <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 /> F INTENDED USE TYPE OF WELL m xr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATI Contractor N ti� - A71&A } <br /> Type of Pump S;4 6 .,l,r_ 9 a{, /c H.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 I <br /> t I 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 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 torwhich this Z <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: �� . <br /> (Draw Plot Plan on Rever Side) <br /> DEPARTMENT USE ONLY <br /> : PHASE t �►+,/6 C <br /> Application Accepted By vDate <br /> Additional Comments: <br /> Phase It Grout Inspection C4. inal Inspection <br /> Inspection By—N. \ in Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE "C' <br /> LESS 1 <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s _.:• <br /> 41,hoz <br /> Received by'-. Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> 'APPLICANT-=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 11601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />