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� - Applications Will$e Processed When Submitted Properly,Completed. Be ul TSl1n aneapprccaiuur U <br /> APPLICATON <br /> FOR OFFICE USE: .j F MAR �MELL <br /> q <br />' a "(For Non-Transferable, Revocable;SuspendaPe) <br /> ENVIRONMENTAL HEALTHPERMIT SAN io Jf!! 3CAL <br /> <_. WATER QUALITY ��j <br /> (COMPLETE IN TRIPLICATE) s '�• r= t°_ r �L�1ff��"�`UXA pp' <br /> Application is hereby made to the San Joaquin Local-Realth Districtfor a permit to construct an install <br /> r s .This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 an t1 `rules and regulations of the San oaquin Local District., <br /> Exact Site Address 69� � /yl ��/ City/Town C H <br /> Phone —` <br /> Owner's Name �� w , City p <br /> Address d, � } 01 <br /> \ <br /> ;'�. 14 License h Business PhoneQ'i <br /> Contractor's Name _ r - Y <br /> �' �' Emergency Phone c <br /> Contractor's Address d � <br /> is Certificate of Workman's Compensatidn Insurance on File With SJLHD? Yes No <br /> / - _ <br /> TYPE OF WORK (CHECK): ' NEW WELL❑ DEEPEN❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL.ABANDONMENT ❑ OTHER ❑. PUMP IN <br /> 57ALLATION 13 -PUMP REPAIR <br /> REPLACEMENT❑ Ji Pit Priv <br /> �t . Sewer Lines y <br /> DISTANCE TO NEAREST: Septic Tank _x F . �_-.- _� - <br /> - � ' ' j <� �� {Other � ~ <br /> Sewage 17isposalField Cesspool/Seepage Pit <br /> I <br /> Property Line Private Domestic Well Public Domestic Well <br /> r INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL r ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE H ❑ DRILLED T Dia. of Well Casing <br /> 13DOMESTIC/PUBLIC li 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION <br /> �; El ROTARY Type of Grout <br /> ❑ DISPOSAL I° r l ❑ OTHER Other information <br /> ❑ GEOPHYSICAL - ii Surface Seal Installed By: <br /> PUMP INSTALLATION: �i Contractor. _ H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work-Done <br /> 6fa!#! cJ <br /> I '� Done - <br /> ximate <br /> PUMP REPAIR: State Work ~"� ApproDepth <br /> DESTRUCTION OF WELL: j Well Diameter <br /> k Describe Material and Procedure <br /> I hereby certify that l'have prepared this application and that the work will be done in accordance with San Joaquin County x, <br /> rordinances, state laws, and rules and regulations of the San Joaquin Local Health 17istrict. <br /> Home owner 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 oril3ub-contracting signature certifies the to "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 /> call f a Gro nsp c on prior to grouting and a)inalrinspec• n.= <br /> Signed X <br /> # Title:. f-, Date. <br /> _ ryIII 4{Draw Plot Plan on Reverse Side} <br /> Ih I, FOR DEPARTMENT USE ONLY <br /> PHASE I � �� Date <br /> Application Accepted By, <br /> `Additional Comments: <br /> Phase it iGrout Inspection h e II incl Inspection pT <br /> Inspection By <br /> Date Inspection By Date ��c! <br /> Fee Is Due: ❑ ANNUALLY ❑f PER UNIT EI PER SITE ❑ EACH ❑ January 1 8 RBC ived By January 31 E] July 1 &Receiv July 37 <br /> REMIT <br /> 1! 1F BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE i- REMITTED AMOUNT <br /> IL <br /> IEEE <br /> LESS 1j <br /> PRORATION <br /> PLUS <br /> PENALTY " <br /> OTHER <br /> I OTHER <br /> Received by - <br /> ate It Receipt No Permit Na. - - <br /> Issuance Date Mailed Receipt <br /> 1601 E.HA2ELTON AVE.,P.D.Box 2009 STOGNTON,GA 9 <br /> APPLICANT—RETURN ALL COPIES TO:`--ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />