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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) UMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit toconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaqu' Clounty rdinance. o. 1662 nd the rules annd/regulations of the Sa Joaqul Local Health District. <br /> Exact Site Address�. We �� '" j�/X,[,• �B C�!tom 61� City/Town ���/�� <br /> Owner's Name Phone <br /> Address C City <br /> Contractor's Name License# /' Business Phone <br /> Contractor's Address .7Emergency 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❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t <br /> Sewage Disposal Field i70`� Cesspool/Seepage Pit Other <br /> Property Line Privates Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 166 a)a-t6 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout �,' &_710)U 2 v <br /> ❑ DISPOSAL ❑ OTHER Other Information V <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -6 <br /> - <br /> PUMP INSTALLATION: Contractor ' T <br /> Type of Pump H.P. J" <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 p <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f;! <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit10 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"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 /> I will all for a Grout Inspec�h prior to groutin and a final inspection. p <br /> Signed X '� Title: Date: <br /> 4 (Draw P Ian on Reverse ide) <br /> OG FOR DEPARTMENT USE ONLY <br /> PHASE _ <br /> Application Accepted ey � Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S f b O <br /> LESS �1 <br /> PRORATION r <br /> PLUS r� <br /> PENALTY <br /> OTHER & (. t <br /> OTHER I <br /> o <br /> Received by Date Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />