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' T Applications Will Be Processed When Submitted Properly Completed. Be Sure a Application. <br /> FOR OFFICE USE: APPLICATION �i � �' <br /> (For Non-Transferable, Revocable�,�5u ip J911L) MP&WELL <br /> WA-W <br /> ENVIRONMENTAL 1­194T�H PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUAL .. ; R � f� � <br /> Application is hereby madetotheSan Joaquin Local Health Districtforapermitto�onstructaN%rinstall 4elnr�r.�v eindescribed.This application is <br /> made in compliance wit San Joaquin ounityprdinance No.1862 and the rules and regulatigns Otte in L al Health District.E <br /> Exact Site AddressJ� 7 CitgJx n f/i6�`61 � <br /> r <br /> Owner's Name + r Phone <br /> Address 7 <br /> city :- <br /> Contractor's Name �o +. ., License#/�, � ? 3 k Business Phone' .�?� —�C <br /> Contractor's Address ., ' , - Emergency Phone (Q(.. fit. <br /> Is Certificate of Workman's Compensation Insurance n 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❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank J Sewer Lines Pit Privy <br /> .t <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-WeII.Excay.ationL_ <br /> O'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN t Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ,f Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor l(_� <br /> Type of PumpH,P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IrState Work Done <br /> DESTRUCTION OF WELL: Well Diameter -z_. Approximate Depth <br /> Describe Material-and.P_rocedute' r <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 /> Homeowner 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 Califorhia." <br /> Contractor's hiring or sub-contracting signature•certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to-wdrkman's-compensation laws of California." <br /> I wi I CII for Grout Ir{sp�gc on prior to grouting and-a-final Inspection„ <br /> Signed Xitle:..- Date: <br /> (Draw Plot Plan on Reyers Side) <br /> FOR DEPARTMENT USE ONLY <br /> •.-_ <br /> PHASE I f�' <br /> Application Accepted By l~ Date <br /> Additional Comments: <br /> pPhase II Grout Inspectionhase Ili Final Inspection <br /> Inspection By Date Inspection By Date 3 <br /> + f <br /> Fee Is Due: ❑ ANNUALLY 1:1 PER UNIT- ElPER SITE 1:1EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By Ju$y 31 <br /> ' BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION -� DATE DATE REMITTE=D AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE S S <br /> LESS <br /> PRORATION <br /> 2 <br /> PLUS <br /> PENALTY <br /> OTHER '" <br /> OTHER - <br /> • . s <br /> Received by Date s Receipt No.' Permit No. I suance Oate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ;ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 962011 <br />