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Applications Will Be Processed When Submitted Properly Compl ojB rue To Sign The Applicfl6n. <br /> FCR�OFFiCE USE: APPLICATION �98� <br /> E (For Non-Transferable, Revocable, Su endablaM <br /> ENVIRONMENTAL HEALTH PERMIT, <br /> SPNr �)MP&WALL <br /> svRicl <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HFp�L-'H ID <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance tacg qu�=ou rdinance-No.1862 and the rules and regulations of the Joaquin ae+-Health District. <br /> Exact Site Address ((pp City/Tow —_ <br /> L �RASc�AIg, <br /> Owner's Name . Phone_-- <br /> Address ' City. T ` - -----�- <br /> Contractor's NameLT!`� M S License Business Phon rot <br /> Contractor's Addressr A-9 Emergency Phone - a <br /> is Certificate-Of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> N TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M' 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 <br /> INTENDED USE TYPE OF WELL <br /> ' ❑,/INDUSTRIAL ❑ CABLE TOCL Dia. of Well Excavation <br /> u DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑'OTHER Other Information <br /> ❑ GEOPHYSICAL 9 SurfaSeal I s a Jq?y: <br /> PUMP INSTALLATION: Contractor rJ + <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 /> L <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 4,o workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I ce hat in the performance of the work for which this <br /> permit is issued I I employ persons subject to workman's Corr o laws of California." <br /> I will call r n ection pri �utl a final inspectio <br /> s Signed X Title: Date: y . <br /> ` (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phaa If Grout Inspection P e III Final Inspection <br /> f Inspection By (Date <br /> Inspection By Date e <br /> i Fee Is Due. 13 ANNUALLY <br /> ANNUALLY ❑ PER UNIT E PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION i DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT <br /> Y <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHER <br /> 4: <br /> OTHER <br /> CColo <br /> � <br /> Received by - Date Receipt No Permit No. isivancle Date Mailed Delivered <br /> e <br /> -. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />