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While <br /> Submitted Properly Completed. e <br /> Applications Will Be Processed <br /> FOR OFFICE USE: " APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) U P V' 112 0 1981 <br /> i <br /> s-: <br /> s ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SAN ;It-?�?C? Ptii .f�J�,l;� <br /> - <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for apermittoconstructand/or,installthework.herein• ,esonlb��ljTh�s nis <br /> made in compliance with San Joaquin County Ordinance No. 1862.and the rules a d regulations of the San Joaquin Local Health District. <br /> ��� ,L`..,. T City/Town <br /> ! Exact Site Address 'e <br /> *A•. _ Phone <br /> Owner's Name C �� <br /> :Y•t = y :::' ' Clty <br /> Addressss Phone <br /> Contractor's Name License# Busine <br /> o2L> <br /> li.�-y--e <br /> Contractor's Address _ �''� lip <br /> Emergency Phone <br /> No _ <br /> i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL <br /> � DONMENT ❑❑ OTH ROD ITI PDP INSTALLAT ON.❑D PUMP REPAIR <br /> WELL CHLORINATION 11 WELL <br /> REPLACEMENT Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic.Well <br /> INTENDED USE: I TYPE OF WELL <br /> 'CABLE <br /> ❑ .i ❑ TOOL Dia. of Well Excavation <br /> INDUSTRIAL ` <br /> ` ❑ DRILLED Dia. of Well Casing <br /> 19 DOMESTIC/PRIVATE Gauge of Casing' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION t ❑-GRAVEL PACK Depth of Grout Seal <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> El DISPOSAL 11 OTHER <br /> t <br /> r surface Seal Installed By: <br /> 11 GEOPHYSICAL' . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> I : <br /> PUMP REPLACEMENT: � - . I -State Work Done <br /> PUMP REPAIR: ; ❑ State Work Done <br /> Well Diameter. Approximate Depth <br /> DESTRUCTION OF WELL: _ <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 re.gfulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature;certifies of California." <br /> 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 <br /> l <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the per <br /> of the work for which the i <br /> permit is issued, I stiall employ persons subject to workman's compensation laws of California." v 1 <br /> I will for a Gro spe n prior to grouting and a final inspec <br /> Title: __ ,J — Date: <br /> Signed X ' <br /> (Draw Plot Plan on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY r ) <br /> CX <br /> PHASE I Date O;0-72){ <br /> Application Accepted By ; <br /> Additional Comments: hale I I Final Inspection <br /> Phase 11 Grout Inspection Date <br /> Inspection By :Date Inspection By <br /> t ' By 31 <br /> Fee Is Due: F-1ANNUALLY ❑,PER UNIT' El PER SITE ❑ EACH',. ❑ January i &'Received By January 31 July 1 S Received EMITuIy <br /> _ BILLING It ..i REMlITTANCE $ AMOUNT DUE CHECKED <br /> BASE ',! EXPLANAT40N PATE t DATE. REMITTED ' AMOUNT x <br /> FEE ,1 � <br /> LESS ; <br /> PRORATION <br /> PLUS t� <br /> PENALTY <br /> ? OTHER { <br /> OTHER <br /> Received by Date <br /> Receipt No. � Permit No ..-issuance Pate . Mailed Delivered- <br /> 1601'El-HAZELTON AVE.,P.O.Boz 2009 STOCKTON;CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />