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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Ap Lic <br /> FOB,OFFICE USE: APPLICATION j ? <br /> (For Non-Transferable, Revocable, Suspendable) / PU W <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, ��;Zj i(�� i r LWAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thew erein desg4Lt ..tTljljyp31iGa i��f <br /> made in compliance with Sand uin.Cau rdinance No. 1862 and the eand regulations of the Sa J a alth District. <br /> Exact Site Addre f l C� v City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# 3 Busi ss Pho e <br /> Contractor's Address = Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION 13R PUMP REPAI {� <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 /> �) DUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> DOM OMESTIC/PRIVATE 11DRILLED Dia. of Well CasingESTIC/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. Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H-P. <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <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 r <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 /> Contractor' g or sub-contracting signature certifies the following:"I c fy that in the performance of the work forwhich this j <br /> persd, I s all em y p ons subject to workman's compen a 'on laws of California." <br /> 5tru <br /> i Inspe n pri to groutin and a final inspect `Signed X _ Title: Date: / � ,r — (Draw Plot Plan on Reverse Side). <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1��1i�..+ � rY��� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection Byaiu�� Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 6 BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> — / <br /> 05?0 <br /> FEE <br /> LESS <br /> PRORATION � <br /> PLUS <br /> PENALTY <br /> OTHER 1I S'8� k� Nfe{ SarliN� %1v LONG�Qe�C <br /> OTHER <br /> Received byDate Receipt No. Permit No. Is ance Dde aMailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />