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Applications Will Be Processed When Submitted Properly Completed.Bebur! +ob+ n e cap...... <br /> FOfOFFIC:EU:SE <br /> APPLICATION <br /> (For Non-Transferable, Revocable p 'de <br /> . UMP&WELL <br /> ` ENVIRONMENTAL HEALT MIT_ �ga� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,}UN 2 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th�e}vyCc h- <br /> \Se�lp� cribed.Thisapplicakionis <br /> e ru I of ' { T� <br /> ocal Health District. <br /> I <br /> made in complianith San Joaquin Co y egul <br /> � �' <br /> � <br /> Exact Site Addre n1 f <br /> f <br /> Owner's Name Phone <br /> I Address City <br /> Contractor's Name License#�a Business Phone 7278 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensatio nsu ce on File With SJLHD? Yes -- No <br /> f TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONI DESTRUCTIO,.,NO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 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 TOOL Dia. of Well Excavation <br /> i ❑ DOMESTIC/PRIVATE M ❑ DRILLED - Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC , <br /> '-" ^❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION "` _ -❑=GRAVEL PACK w T Depth-of Grout-Seal -.— <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Q <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> ` PUMP REPLACEMENT: I ❑ State Work Done <br /> PUMP REPAIR: ❑ state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> I , <br /> Y , <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 /> t Contractor's hiring or -contracting signature certifies the following:"I certify that in the performance of the work torwhich this <br /> permit is is ued, employ persons subject tb;workman's compensation laws of California.' <br /> I will r a ins ction prior to grouting and a final inspecti <br /> Title: <br /> Signed X <br /> Date: <br /> (Draw Plot Play on Reverse ide) <br /> - - -- '~ - "'FOR=DEPARTMENT USE ONLY <br /> PHASE - �` <br /> '' Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection B Date <br /> Inspection By Date. y t <br /> ' Fee Is Due: ❑ ANNUALLY ❑.PER UNIT v APER SITE C1EACH ❑ January 1 &Recei January 31 ❑ July 1 &Receiv FEMITBy uly 31 <br /> F <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER r`� <br /> OTHER "Ply- <br /> Received by Date Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />