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Applieations Will Be ProcessedWhenSuUmlilea rrvpcnr w•rrN•�.�... ..� �+•-•� •--•o •• �� - <br /> F6]Fi j0FF1:CEUSE: .-APPLICATION <br /> (For Non-Transferable;Aevocable,Suspendable) <br /> F.�NIV�F ONMENTA•L HEALTH PERMIT"' h` <br /> :$: <br /> WATER QUALITY` ::. <br /> (COMPLETE IN TRIPLICATE) " ' <br /> Application is hereby made to theSan:Jdaquin Local Health District fora permit to construct and/or install the work herein described.Thin application is <br /> made in compliance wi aJoaquin ounty -rdinance No. 1862 and the rules and regulations of the Sam p�in,Loc I f4olth 019trict. r <br /> Exact Site Address >� �` City/Town � � �l----,-- --- <br /> Owner's Name Com. _Phone <br /> Address <br /> l' City <br /> Contractor's Name- I License �, - Business Phone <br /> Contractor's Address A^ Emergency Phone G <br /> Is Certificate of Workman's Compensation Insurance on File With.SJLHO? =Yes No <br /> TYPE OF WORK (CHECK):,.- NEW.WELL DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ <br /> IIVELU CHLORINA ffE�IV ❑ ' WELL'ABANDONMENT'❑ : OTHER ❑ -PUMP INSTALLATION. PUMP-REPAll1❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank -:Sewer Lines I _u. Pit Privy <br /> `Sewage Disposal Field' FCesspool/Seepage Pit Other <br /> ;_'Property tine,,ine,• Private DomesticjlVelI Publics omestic Wet#- <br /> INTENDED USE TTYPE OF WELL29 <br /> ❑ INDUSTRIALGABLE TOOL,,_ x Dia. of Well Excavation , f1„ <br /> ®�-D'OMESTIC/PRIVATE. ❑ DRILLED ...-__ -Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC. . DRIVEN Gauge of Casing <br /> GRAVEL PACK Depth of Grout Sea] <br /> IJ IRRIGATION ❑ <br /> ❑ CATHODIC PROTECTION 11 ROTARY •:r,Type.rof Grout -- <br /> ❑ DISPOSAL ❑ OTHER Other Information. <br /> 11 GEOPHYSICAL: Surface Seal-installed By: <br /> � - -- <br /> ,; .PUMP-(INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT_'": ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth --.- <br /> 4 Describe Material and-Procedure - <br /> I hereby•certify.thaT1 have prepared this application and that the work will be done in accordance with San Jowlilln County <br /> ordinances State laws,anb rules-and regulations of-the San Joaquin Local Health District. .. i 1 <br /> Warne owner or licensed agent'ssignature certifies-the following:"I certify that in the performance of the workfor-which this permit <br /> is issued-, I shall not eploy any'"rson in such manner as to become subject to workman's compensation laws of Calif <br /> mornin." <br /> Contractor's hiiting or sutrcontracting•signature•certifies the following:"I-certify.that-in.the performance.of the woTkior•which this11 <br /> permit is issued;I'shall employ persons subject to workman's compensation%flaws of California." <br /> will call for, Inspection prior.,to grouting and a final inspection. _ - s <br /> � a F r� 4� .. Date: <br /> Signed;X � �� � -� '�� Title: <br /> (Draw lot Plan on Reverse Side) <br /> }��,�„� � � { � 1\ +.fir,•.� � <br /> FO EPART NT USE�ONLY '* t <br /> PHASEf_ ., I <br /> L <br /> Application AcceptedByF <br /> Additional Comments: + € <br /> P.hase.'4 far i Inspection Phase,Ili-Final Inspection <br /> Inspection By Date -,� Inspection By - Date <br /> - Fee 15 Due: El ANNUALLY'. -❑ PER UNIT'❑-1'E>�'SITE El EACH F-1January 1 &'Received By January 311 ❑`July 1 &Rereived ByJlily 31 <br /> f-� REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE 1. GHECK,EC) <br /> 'BASE EXPLANATION D TE DATES REMITTED AMOUNT <br /> I FEE <br /> iLEss <br /> C PRORATION <br /> PLUS <br /> PENALTY 6 <br /> OTHER / <br /> OTHER �! <br /> Received ey _ Date Receipt No. Permit No. Issuance Dale Mailed - Delivered <br /> I <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITlS£RVICES 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKTON,CA 95201 <br />