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Application Wt3%rte4d 1enPPLICATION <br /> ilted Properly Compl � B lSi SgnTheAppli . <br /> FOR OFFICE USE: ` 3� <br /> `" a ( YjNon-Transferable, Revocable,Su ableh u G V <br /> SyO1 ]� Py <br /> MP&WELL <br /> S � a ENVIRONMENTAL HEALTH PERMIT �f�3,N <br /> (COMPLETE IN TRIPLICATE) l l F+ uIN LQ``r�AL WATER QUALITY SAN �' D1s-TPIGT <br /> Application is hereby made to theSSrp,& 1�c �It9&Jrictforapermittoconstructand/or ii 4rvZ rk herein described.This application is <br /> made in compliance with San Joaqui�t ht Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/TownC&. <br /> Owner's Na e 144 Phone q -ZI I- <br /> Address e -) fE e ! City t-A <br /> Contractor's Name /�/`r�-� License# W7_1;37'_ Business P one -j9_4t �1 <br /> Contractor's Address /S- Ci�11 � ]f' 1�� Emergency Phone �Q " <br /> Is Certificate of Workman's Compensation Insurance on Fi eT With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR IJ <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 01 DOMESTIC/PRIVATE ❑ DRILLED pia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'mss n <br /> Type of PumpH.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 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 forwhich 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. �r <br /> Signed X Title: Date: _±"i '~ <br /> (Draw Plot Plan on Reverse S e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f _____ � _ _ <br /> Application Accepted By _ Date <br /> Additional Comments: <br /> se I rout Inspection h I trial Inspection` <br /> Inspection By Date Inspection B /1Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> VJ If 11 F1 <br /> AMOUNT <br /> FEE � f <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> OTHER E <br /> Received by Date Receipt No. Permit No. I5 uance to Mailed Delivered <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />