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Applications Will Be Processed When Submitted Properly Completed. a tion. f <br /> FOP-OF FtcE USE: APPLICATION p <br /> (For Non-Transferable, Revocable, Sindable) p�MLL <br /> ���ENVIRONMENTAL HEALTHMI <br /> SEP 29 1981 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 1r <br /> Application is hereby made to the San Joaquin Local Hdalth District for a permit toconstructal (inst&-QW&# t(@&o. ascribed.This application is <br /> made in compliance with Si JQaq inn Count rdirap ce No. 186 and the rules and regulatiWAUfFf;al)I He'altq District. <br /> Exact Site Address 1W aVF �a City/Town <br /> Owner's Name IlePhone <br /> Address a Q!• H City <br /> Contractor's Name , ��� �L/ iyti ..�1 License# Business Phone r 6 Z 1 <br /> Contractor's Address Emergency PhoneS <br /> Is Certificate of Workman's Compensation Insu ce on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): ' NEW WELL DEEPEN t3 RECONDITION 13 DESTRUCTION ETs <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLATION U- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST- """"SepTank Sewer Lines <br /> Pit Privy" <br /> I: <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 11(CABLE TOOL Dia. of Well Excavation w <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing y s` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing VC <br /> ❑ IRRIGATION 2 GRAVEL PACK Depth of Grout Seal f <br /> k , <br /> ❑ CATHODIC PROTECTION M<OTARY Type of Grout <br /> ❑ DISPOSAL. ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urface Sea talled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑,State Work Done <br /> Pt M14 REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Wed Diameter y Approximate Depth <br /> y/ 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, st and rules and regulations of the San Joaquin Local Health District. <br /> Home o er or license agent's signature certifies the following:"I certify that in the performance of the work forwhich lhispermit <br /> is iss d, 1 shall not a loy-any-person-in-suchr as to become subject to workman's compensation laws of California." _ <br /> f} C tractor's Kiri o ub-contractin to esti" s he 1 :"I certify that in the performance of the work for which this <br /> rmit is issued, al plo er ct It ` m s compensation laws of California." `t <br /> I will c I r a ro iih. spec Ing end a " al inspectiu <br /> Signed X k Q <br /> I ,Title::. �.� - - .l_ Z <br /> Date: <br /> t (Draw Plot Plan on Reverse Side) " `` y` -� r .a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I + <br /> Application Accepted By '`- - ate y C)-8 1 <br /> Additional Comments: �I <br /> lase 1 Grout In ection <br /> Phas 111 Final 1 pection <br /> Inspection By Inspection By Date awl' —ep Y <br /> Fee Is D`�ue: ❑ ANNUALLY El UNIT. El SITE EACH ❑ January 1 &Received <br /> y 6y January 31 ❑ July 1 &Received By July 31 <br /> BILLING_ REMITTANCE ,E$ REMIT <br /> BASE :EXPLANATION,-. ;...r=- -�,�a„ -- z 4__�_.__ AMOUNT DUE C�ECKED C <br /> DATE DATE REMITTE -= 'AMOUNT <br /> l <br /> FEE ��tr��. - r <br /> LESS I} f Q <br /> ! PRORATION v I a <br /> PLUS <br /> PENALTY- r <br /> r <br /> OTHER ` <br /> OTHER <br /> . + <br /> s Received by Date Receipt No. Permit No. ;I suance ate Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES` 1601 Ek HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />