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Appllca WIII Be Processed When Ski ted Properly Completed. seSure feign nneAppllcMlo� Jp+ f T <br /> '�FbR't7FFICE USE: AUG 13 1979 PLICATION 13 1 �j►ffJ <br /> (For Non-Transferable, Revocable,Suspendable) G <br /> SAN JW,0,U1bN`11@RfttMENTAL HEALTH PERMIT SAN Ja pU1�V <br /> HEALTH DISTRICT WATER QUALITY HEALTH �OCaL <br /> (COMPLETE IN TRIPLICATE) c QTh. <br /> Application is hereby made to the San Joaquin Local Health District torapermittoconstruct and/or install the work hereink� I Is application is <br /> made in compliance with S Jq In Cou y Or I ce iVo. 1862 and the rules and regulations of the San J�gusQLo e Ith Dist ict. <br /> Exact Site Address `��I-� N City/Town o� <br /> Jf <br /> Owner's Na e <br /> �l r' i, - L.� ��� Phone �� g <br /> City <br /> Address j <br /> ga <br /> Contractor's Name <br /> �L License Busines hone i <br /> Contractor's AdAVL <br /> dress Emerge�ncPh� i <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 ❑ P INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ ?� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepagefit a Other <br /> Property Line Private Domestic Well Pub1ic 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN ,_... ,,Gauge of Casing <br /> 13 IRRIGATION <br /> ❑kGRAVEL7PACK -------�-Depth'of Grout Seal <br /> i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br />�. 13 GEOPHYSICAL Surf e Sgal I�rsted By: L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> UMP REPLACEMENT: 61-15t-ate Work Done f <br /> PUMP REPAI : ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 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 <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 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 /> i Contracto ' Ing orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> s sued, 1 shall a persons subject to workman's compe ation laws of California." <br /> I Grout In ec n prior to grouting and a final insp ' n: �� <br /> Title <br /> Date: <br /> Signed <br /> } (Draw Plot Plan oneverse Side) <br /> FO D PARTMENT USE ONLY <br /> PHASE I - ' <br /> Dat <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha a 111 Final Inspection _�� <br /> Inspection By Date Inspection By Date <br /> i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> j LESS <br /> {1 PRORATION <br /> PLUS <br /> i PENALTY <br /> OTHER <br /> OTHER <br /> Z_ <br /> Date Receipt No. Permit No <br /> Issuance Date Mailed Delivered <br /> Received by- _ y <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />