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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign-The Application. <br /> FOR.OFFIr�_ -USE; APPLIC#TION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> `pLJMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT o <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1 <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is p� <br /> made in compliance with San Joaquin County Ordin nce No. 1862 and the rules and regulations the San J; q In Local Health District. <br /> Exact Site Address o1 � ynt- • - <br /> 1t✓n: <br /> Owner's Name X e ��/ Phone <br /> Address _ o %� °S /�QPI TQ�a /@il- __ City <br /> Contractor's Name License Business Phone �`J`5�S-&9,5 <br /> Contractor's Address 136 ' Emergency Phone <br /> Is Certificate of Workman's Compensation lnsu5j>ce on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER D PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ s <br /> DISTANCE TO NEAREST: Septic Tank 10o 06 / Sewer Lines r .� Pit Privy � <br /> Sewage Disposal Field Cesspool/Seeepage_Pit. Other,/011f_` loo <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ✓ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC ,❑ RIVEN Gauge of Casing �g <br /> O IRRIGATION r�rrr,,'��GRAVEL PACK Depth of Grout Seal <br /> 1:1 CATHODIC PROTECTION ID ROTARY Type of Grout GHQ <br /> ❑ DISPOSAL ❑ OTHER Other Information 6" <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 w61C'will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this ; <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout spectio prior to groulin nd a final inspection <br /> Signed X itle: Date:, <br /> (Draw Plot F61n on Reverse Side) <br /> FORD PART ENTUS NLY <br /> PHASE I <br /> 9 <br /> Application Accepted By ''—� Date T <br /> Additional Comments: <br /> Phase li Grout Inspection Phase III Final.Inspection <br /> Inspection By Date Inspection By Date �y— �— <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> $ REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANAT40N DATE DATE REMITTED AMOUNT DUE CHECKED 1r <br /> AMOUNT <br /> FEE p n <br /> LESS <br /> PRORATION <br /> 4 PLUS <br /> i <br /> PENALTY <br /> i} OTHER <br /> '1 '4 OTHER <br /> M <br /> t Received by ate Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> �. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br /> ,1 <br />