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Applications Will Be Processed When Submitted Properly Completed. ueTo Sign The Applicatid — <br /> I ­6 OCE USE: APPLICATION APR $ 1980* (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMI�AN ,1®AQ UIIN LWA WELL <br /> (COMPLETE.IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> AppI ication is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San a uin ounniv 1862 rules and regulations of the SalaL g!t Dista t } <br /> Exact Site Address A City/Town a uq <br /> Owner's Name / CL/ '+� Phone CT J!!!=, <br /> Addressg City <br /> Contractor's Name fill!M License#Y 7 Business Phoy�e '''L <br /> Contractor Is Address M ` �9 �f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy a <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ^' <br /> INTENDED USE TYPE OF WELL <br /> ❑ANDUSTRIAL ❑ 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 /> vl <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Q <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Q1J'§t`ate Work Done <br /> � . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �9 <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 hirin or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permi iss I shall emplo rsons subject to workman's compensation laws of California." <br /> j <br /> I II t r t Inspe 'on pr' r to grouti g and a final inspect' <br /> Signed X Title: Date: j <br /> (Draw Plot Plan on Reverse Side) <br /> FOJI DEP RTMENT SE ONLY a <br /> PHASE I �y� � <br /> Application Accepted By Date <br /> el <br /> a " I <br /> Additional Comments: i <br /> Phase II Grout Inspection ha II al In eition <br /> Inspection By Date <br /> � Inspection Bya� <br /> i - Fee Is Due: 11 ANNUALLY ❑ PER UNIT LO.PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> I <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED '♦ <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER' f t <br /> OTHER f j <br /> B a <br /> - Received by - Date Receipt No. Permit No. IssuaInce bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 85201 _+� <br /> � t � <br />