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Applications Will Be Processed When Submitted Properly Completed..B�e To Sign The ion. <br /> FG�'QFFICE USE: APPLICATION SEP ��ff <br /> e) <br /> spe <br /> ,,(For Non-TransferableRevocableSundabl <br /> ¢•... Jl� WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN f �H''DIs <br /> (COMPLETE IN TRIPLICATE) ,/ _ QUALITY <br /> Appl ication is hereby made to the San Joaquin Loral Heal th District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health [District. <br /> Exact Site Address klO f TP � ll ? FB2 City/Town _LcSCAL" _ J <br /> 11 <br /> Owner's Name Phone 632 -6 11 /,�j�'7 <br /> Address f City <br /> Contractor's Name-CA.WA?15J 061U-111,1C3 CCS License#sV 2,3E2 Business Phone . '�y��2"� 2 <br /> Contractor's Address 36". J./,rL 1;3V11r1 Emergency Phone_ <br /> Is Certificate of Workman's Compensation In on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _CI . Sewer Lines# Pit Privy <br /> Sewage Disposal Field 4i0CJ Cesspool/Seepage Pit Other <br /> Property Line .S Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL —" <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �fNIDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing � � <br /> ❑ IRRIGATION V GRAVEL_ PACK Depth of Grout Seal VFT <br /> ❑ CATHODIC PROTECTION -ROTARY Type of Grout lz5 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> f <br /> Type of Pump H.P. <br /> PUMP'REPLACEMENT; ❑ State Work Done <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 /> 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 /> I <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 will ca I fqf a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: —chow Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR PARTME T USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> (]/ -/P s It Grout I spect!on Phase II Final I pection f <br /> Inspection By /F/ i + � �ate Inspection By Date ��/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE <br /> 3 -� <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER <br /> Y <br /> Received by Date Receipt No. Permit No. I suance Date Mailed Delivered <br /> Ilk. � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1$01 E.HAZELTON AVE.,F.O.Box 2009 STOCKTON,CA 95201 <br /> •�.�,— <br />