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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I, <br /> r APPLICATION �' <br /> FOR OFFICE USE: <br /> i (For Non-Transferable, Revocable;Suspendable) (cUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT // C0 <br /> i` WATER QUALITY ! 41, p + <br /> li(COMPLETE IN TRIPLICATE) ?` ' <br /> ..Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> o made in compliance wSan quin County Order nce No..1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> i Exact Site Address <br /> G 5;'.;xl / <br /> y Phone ; <br /> p Owner's Name , f - 'i d <br /> City r� <br /> Address n1,'ILicense# Business Phone <br /> Iy Contractor's Name I <br /> Contractor's Address Phone <br /> Emergency <br /> I Is Certificate of Workman's ompensation Insurance on File With SJLHD? Yes No <br /> ,�. <br /> j TYPE OF WORK (CHECK)i NEW WELL❑ DEEPEN 1:1RECONDITION 11DESTRUCTION11 i <br /> Is WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> F REPLACEMENT❑ l <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other i <br /> Sewage Disposal Field <br /> Cess Seepage Pit <br /> Public Domestic Well <br /> Property Line Private Domestic Well s <br /> INTENDED USE TYPE OF WELL <br /> C3 CABLE TOOL Dia. of Well Excavation <br /> ❑ I TRIAL <br /> i€ 13 DRILLED <br /> Dia. of Well Casing <br /> i3'DOMESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IF <br /> 11 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal i <br /> 'I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> !� PUMP INSTALLATION: Contractor n --- <br /> Type of Pump H.P. <br /> F li ❑ State Work Done �i <br /> �i PUMP REPLACEMENT: ;, <br /> PUMP REPAIR: ❑ State Work Done r <br /> Weil Diameter Approximate Depth <br /> DESTRUCTION OF WELL: li <br /> Describe Material and Procedure <br /> !I l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> it <br /> +i 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 forwhich 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 /> i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Grout Ins a 7t prior to grouting and a final inspection. / �J <br /> h Signed <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ' FOR DEPARTMENT USE ONLY <br /> I PHASE <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection ph a in Inspection / <br /> r <br /> Inspection By Date i <br /> Inspection By Date r /✓ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 0 July 0&ReceivedREMITuIy- K <br /> BILLING REMITTANCE. AMOUNT DUE;' CHECKED <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY } <br /> Y OTHER <br /> i. <br /> OTHER <br /> Iss <br /> Received by •$'Date Receipt No, ermit o. <br /> ante D to Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISERYICES .P - <br />