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Applications Will Be Processed When Submitted Properly Completed.Ber$urerTo�5iip-�hej'Apptication. <br /> FOR OFFICE USE: APPLICATIONL,� � ` <br /> s r (For Non-Transferable, Revocable, spendable) P, M ELL <br /> ENVIRONMENTAL HEALTH PERMIT 1V 1211632 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructi'06rtnstallthe�n+o k eEre�l i.iescribed.This appiication is <br /> "ice dgl t- t �r3SjA Ali <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and reguiati ns�of 1:he Sari Dago rn ocal Health District. <br /> Exact Site Address_�v 0 __3 -1 - 4 ' - -! City/Town - <br /> Owner's Name Phone <br /> Address d ��o a „ > t City <br /> Contractor's Name ; 2 `License# Business Phone - <br /> Contractor's Address p mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q�} <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ 'RECONDITION 11 DESTRUCTION❑ p <br /> WELL CHLORINN 11 WELL ABANDONMENT IJ -OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT iATI <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 /> r INTENDED USE --- TYPE OF WELL y r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> yLl DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION. ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "" _ H.P. <br /> PUMP REPLACEMENT: ��S#ate Work Done <br /> PUMP REPAIR: N]State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter t .Approximate Depth <br /> Describe Material and Procedure f 1 <br /> I C- <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 /> I 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 forwhich 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. —� <br /> Signed X /!fir �! �(I e � u��J Title: Dater <br /> (Draw Plot Plan on Reverse Si e) <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I t,r <br /> Application Accepted By ��\�7.3ttti- �''�°`- Date <br /> Additional Comments: <br /> Phase tl Grout Inspection P has III Final Insp i <br /> J\NJIns ection B ate <br /> Inspection By—= OIC Date P y <br /> Fee IS Dile: 11 ANNUALLY PER UNIT PER SITE `-❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE .REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. <br /> Permit No. r - Is ante 1e Mailed Delivered -' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Sox 2009 STOCKTON,CA 95201 <br />