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r I' tions Wil` hogissed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICEC1SE: QtifV APPLICATION <br /> _ <br /> F� �c}rVon Transferable, Revocable,Suspendable} MP&WELL <br /> Far <br /> J* .�t`v ENVIRONMENTAL HEALTHr PERMIT ( Ar <br /> �� ��" _ ,r ,,,•:�. . „ ,,,..nt�. . <br /> (COM LETS 1N TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermn <br /> ittocostructand/orinstallthework herein described.This application is } <br /> made in compliance wi h-San Joaquin County.Ordina ce No. '1 2 and the rules and regulations of the San Jo Wn�Local ea�trJ <br /> Exact Site Address City/Town <br /> OF Phone <br /> 00 <br /> Owner's Name City <br /> Address <br /> License#� �Business Phone <br /> Contractor's Name <br /> Contractor's Address Emergency Phone <br /> �-� I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 4. � - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPENR❑ E O❑ IT' PUMP INSTALLATION�P REPAIR❑ v I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines + Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit, Other - `F <br /> Property Line Private Domestic Well Public Domestic-Well <br /> r <br /> INTENDED USE <br /> I TYPE OF WELL <br /> 11INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r <br /> E] DRILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PRIVATE - - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal y <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> 13 State Work Done Z <br /> proximateepth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and rocedure j <br /> I hereby certify that I have prepared this application and th he work will be one in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local He th District. � <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof 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 /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> persons subject to workman's compensation laws of California." <br /> permit is issued, 1 shall employ <br /> r <br /> I <br /> 4n5out Inspec an r' r to grou• g and a final inspect! a <br /> I Title• <br /> Signe <br /> (Draw Plot Plan on verse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� DateF <br /> Application Accepted By f <br /> Additional Comments: se Ill Final Inspection <br /> Phase II Grout Inspection 3 t <br /> Inspection By <br /> = Date Inspection B ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITuly 31 �h <br /> N BILLING REMITTANCE - AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE` kO <br /> LESS a ' <br /> PRORATION <br /> PLUS i - <br /> PENALTY f. <br /> OTHER - - <br /> OTHER <br /> Received by Date <br /> Receipt No. Permit No - I suance ate Mailed- Delivered - <br /> ' 1601 E.HA2ELTON AVE.,P.O.Boa 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> + <br />