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Applicat ons ill a Processed When Submitted Properly Complyi ti^ <br /> Sign The-Application. <br /> aFo,'y,-QFFICE USE: APPLICATION r <br /> } , (For Non-Transferable, Revocable, Suspea <br /> ,1 <br /> LTH PERMIT <br /> ENVIRONMENTAL HEA `� PLKAFY&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit tocon <br /> struc' t d%orinstalltheworkhereinde�r <br /> made in compliance with /Q(, <br /> n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa t it ' ,1�rlbed.This application i <br /> Exact Site Address 6 W 3 /( % City/Town` !.J.e, T,, , Local Health District. <br /> �� <br /> LOwner's Name _ Q % X`,Phone <br /> Address $ J 1 TL]L?, '.'+�-„ "City <br /> C-L;, !F?CztgrL�Nlame 6„L �. (.(l G . . CLicense#7G �� B ins <br /> k one_Ph ~� < <br />- Contractor's Address�' '. [� + Emergency Phone �ass s Ph Q <br /> Is Certificate of Workman's Compensation - <br /> In urance of- <br /> � le With SJLHD? Yes No <br /> '�+.kas ' <br /> .WELL DEEPEN ❑ R`RECONDITION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK}: NEW <br /> WELL CHLORINATION ❑ WELL ABANDONMENT'❑ OTHER ❑ PUMP INSTALLATION ❑ .PUMP REPAIR❑ <br /> REPLACEMENT❑ ` 4; <br /> DISTANCE TO NEAREST: Septic Tan0' „ .* Sewer Lines :-Piitt Privy <br /> Sewage Disposal Field �d Cesspool/Seepage - /Ll Other } <br /> Property Line/W / Private Domestic Well 7A06"r Public Domestic Well e <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation rr <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `SZ Jul <br /> ❑ IRRIGATION ❑. GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION �.� ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed BvIlaw, I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P f <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 /> I <br /> 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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a rout Inspection prior to grouting and a final inspection. <br /> Signed X ! Title;'. Date: 6 r <br /> { (Draw Plot Plan on Reverse Side) <br /> R DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted B Dat <br /> Additional Comments: <br /> Phase It Grout Inspection v Ph t Fina Inspecn <br /> tio " <br /> Inspection By Date Inspection By �� Date l� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ n ry1 &Received By January 31 ❑ July 1 &Received By July 31 r <br /> BASE EXPLANATION BILLING REMIT $ REMIT f <br /> DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY �v <br /> OTHER <br /> r <br /> OTHER <br /> Received by - Date - Receipt No. Permit No. Issuan Date .Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2OD9 KJON,CA 95201 <br />