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itted <br /> ly <br />` ApPlications Will Be Processed When SuAPPLiCArT10NPil-vu. 9 <br /> QFC' I+ <br /> OFFICE USE: (For Non-Transferable,Revocable,Suspendable) pU�p&W�L(- <br /> �P ENVIRONMENTAL HEALTH PERMIT : <br /> WATER QUALITY ork application is <br /> (COMPLETE IN TRIPLICATE) to <br /> Application is hereby made to the San JoaquinLocalHealthDistrictforaPermrulecand regulations of the San Joaquin Cal <br /> deal He.OthThistncis t j <br /> C N .18 (� I <br /> made in compliance w' Sr Jp yin City <br /> Exact Site Address (� E a Phone <br /> Owner's Name City <br /> Address �jy icense usiness Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address +� No w , <br /> Is Certificate of Workman's Compensation in ranee on File With SJLHD? Yes [y <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP IN <br /> ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11 11 Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other —� <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well C <br /> TYPE OF WELL <br /> INTENDED USE @ C� LE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing �C s <br /> ®DED OMESTIC/PRIVATE C3 D ILLZ- <br /> 1 ❑ DRIVEN Gauge of Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout ~� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> � 13 OTHER Other Information <br /> 13 DISPOSAL hh Surface Seal Installed By: <br /> ❑ GEOPHYSICAL I" <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: t ,�i APPraxi�akeaDeP <br /> DESTRUCTION OF WELL: <br /> Well Diameter � 1� <br /> { Describe Material and Proce ure �. <br /> I tE <br /> I hereby certify that I have prepared this application and that the work will be, done in accordance with San Joaquin County <br /> Joaquin <br /> th District. <br /> ordinances, state laws, and rules and regulations of the SanLocal ththat <br /> the performance of the work for which this permit <br /> certify Home owner or licensed agent's signature certifies the following:" Y <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 /> k L <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for r t Inspection prior to grousing and a final inspection. r • Date: <br /> Title: <br /> Signed (Draw Plot Plan on Revers Side) <br /> r <br /> OR DEPARTMENT USE ONLY <br /> )0121 <br /> I PHASE I Date — <br /> i Application Accepted By <br /> Additional Comments: Phase Ill Final Inspection <br /> Phase II Grout Inspection <br /> Inspection By Date <br /> Inspection By Date <br /> r <br /> ❑,January 1 &Received By January 31 ❑ July I &Recewed By July 31 <br /> ❑ PER SITE ❑ EACH REMIT <br /> Fee IS DUB: ❑ ANNUALLY PER UNIT REMITTANCE $ - AMOUNT DUE CHECKED <br /> - - BILLING <br /> BASE � EXPLANATION RATE DATE REMITTED AMOUNT <br /> ta,l1� I W►b s�.i� _ <br /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> -y <br /> PENALTY r - <br /> F ' <br /> OTHER <br /> OTHER fru 1 <br /> P _. tn - <br /> G Permit No. Issuance Date Mailed Delivered <br /> Date Receipt No. <br /> -Received by � 1661 E.Hp,ZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES_TO: ENVIRONMENTAL HEALTH PERM <br />