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Applications Will Be Processed When Submitted ProperlyCompletes tiesure tobig,IneAppncbfan. \ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspen ` Ips- � ELL <br /> ENVIRONMENTAL HEALTH PER I <br /> (COMPLETE IN TRIPLICATE)bird Cwr..w, WATER QUALITY JUN 1 0 1980 <br /> Appl ication is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules an of9AiqanJ0b.&,Gj_MMCh]WAL•District. <br /> Exact Site Address �0�a City/TOVEAA H_Tli,.:;TR!C;T <br /> Owner's Name c Phone <br /> Address f OL �' LS] -3 City a <br /> Contractor's Name /—ALicense#/G 23 2 3 Business Phone <br /> Contractor's Address d Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V No D <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT 91-' <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 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 ❑ 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 INSTALLATION: Contractor - <br /> Type of Pump H.P. t t <br /> PUMP REPLACEMENT: tate Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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:1 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I calf r a Grout nspec ' n prior 10 grouti g and'-a final Inspection. ' <br /> — <br /> Title: /]tel,� Date: <br /> Signed X <br /> (Draw to an on Reverse ide) <br /> R DEP RTMENT USE ONLY <br /> PHASE I t� <br /> Application Accepted $y____ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date �E7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Rec d By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> $ASE EXPLANATION BILLING REMITTANCE ^w, $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 7� <br /> { <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> K_'7 !b --.;,-0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />