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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. A. <br /> FOR OFFICE USE: APPLICATION. ._ l r <br /> ""n <br /> a •Non-Transferable, Revocable,Suspendable) <br /> UMP&WELL <br /> ENVIRONMENTALHEALTH PERMIT <br /> tCOMPLETE IN TRIPLICATE) WATER QUALITY . <br /> Application is hereby made to the San Joaqui rt Local Health District for a permit to construct and/or i nstall the work herein described.This application Is <br /> made in compliance with San Joaquin CoUn Ordina carNo. 1862 and.the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -- -`1- 7City/TownC44 �(�- �� _ <br /> r <br /> Owner's Name ' t: Phone f -2' <br /> Address L9�"G5'e <br /> - City <br /> Contractor's Name ,_ �f r.✓ ��-t 7`' License#T3Sr4 W Business Phone <br /> Contractor's Address �rtQaJ �Caf�J ` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance do File�Jith SJLHD4 Yes ✓� . : No <br /> TYPE OF WORK (CHECK):,. NEW WEI,L0 - DEEPEN ❑ . RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMtAT❑ OTHER ❑ PUMP INSTALLATION I6"�PUMP REPAIR❑ \ <br /> REPLACEMENT❑ '^ <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 r- <br /> 0 <br /> INTENDED USE TYPE OF WELL 41 <br /> 0 INpUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation y <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC r] DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal —� <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout <br /> ❑ DISPOSAL !] OTHER Other Information �0 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: contractor 6-1L.1 - <br /> ' <br /> Type of Pump _ , , H.P. <br /> PUMP REPLACEMENT: ❑ Slate Work Do <br /> PUMP REPAIR: ❑ State Work Done - - <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth — <br /> Describe Material and Procedure <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for wh ich 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 /> permit Is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w t ea l if r a Grout I lid prl to grouting and a final Inspection. <br /> 4 'Title: Cz-'S—'== Date: <br /> '(Draw Plot•Plan on Reverse Side) <br /> FQR DEPARTMENT USE ONLY <br /> PHASEI ` <br /> Application Accepted ByJ"a" Date 7 a <br /> Additional Comments: pp,�� <br /> Phase II Grout Inspection - h Final Inspection Z S 8D <br /> InspectionBy��,Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER U. IT *❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July/ d Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Recelpt No. Perms No. Issuance Date Marled nemd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.sea 200511 STOCKTON,CA 96101 <br />