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App'lications W111 aBrruswaa� ••••�•• " <br /> Fig OFFICE USE: APPLICATION <br /> ;. <br /> :•Y" (For,Non-Transferable;,,Rewocablgl Qt111pUfldablej. • <br /> ENVIRONMENTAL"NEALTPEAMM <br /> IT <br /> I WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) -1 <br /> Application i5 hereby made to the SanJoaquin.LocaiHealthDistrict fdriapermit tocdhptrUctondlor-lnstaRthework herein described.This application is <br /> made in Compliance w'th San Joaquin County dinance No.18 2 and-the"rules and regtilRtlpns°of ihe"Sa�agol�n o afi Heaflh Di tic <br /> own <br /> Exact Site.Address <br /> f <br /> _ Phone <br /> Owner's Name _-Oy <br /> Address ---- s�tcense E3usiness Phone r" <br /> " �l�= <br /> Contractor's.Name- Emergency phone + <br /> Contractor's Address , No <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD:. YOU <br /> _ i <br /> TYPE OF WORLD-(CHECK): "NEW WELL❑ DEEPEN +� REI RO©ITIUN fgVlPANS'TI L AT ON❑❑-F`R'UMP REPAIR❑ <br /> '}WELL CHLOFIf�IATtIs�N ' VtilE�t= ABANDONMENT ❑ OTHER <br /> REPLACEMENT❑ _�_;Plt Privy <br /> 1 C/"� f- Sgwer Lines <br /> '-DISTANCE TO-NEAREST:" Septic Tank,�„ _—.� Cesspool! eepage PIt Other <br /> -. Sewage Disposal.:{�e1d� �._ -- <br /> "-"Property Line, -_�""PrizgtePDomestic:We S[ _ Public Domestic Well <br /> i TYPE DF WELL �r <br /> INTENDED USE ° <br /> ❑ INDUSTRIAL CABi_1E_'OOL - .iia. ofWeft;t~is Atretiol N <br /> aa���rrr ❑ DRILLED .'.Die, of Weil Citslrig. i <br /> DOMESTIC/PRIVATE 11 DRIVEN <br /> Gauge of Casing <br /> DOMESTIC/PUBLIC [3e Ili of Glrout Seal <br /> ❑ kRRIGATIOfda".: _ ❑ GRAVEL PACK P <br /> ROTARY <br /> i.Typo of Grout <br /> ❑ CATHODIC pFCOTECT.ION Other lrifor'fnatinn <br /> "";...❑ "pISPOSAL ❑ OTHER <br /> Su,14ce-Seal installed 8y: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor. - - <br /> - H.P. <br /> Type of Pump 113 State❑ State Work Done <br /> PUMP"REPL-AiCEMENT: - Appro <br /> PUMP REPAIR: ❑ State Work Done <br /> ximate Depth <br /> DESTRUCTION OF WELL-., J Well Diameter - - - <br /> spescribe.MateriaLand�Frocedure..=..__..._ <br /> !� _ <br /> I hereby certify that 1,have prepared this app4ication <br /> and the_wulh Will be done:in accordance with San Joaquin County <br /> ordinances, state laws,and miles and regulatio .1nihotierformance of the ns of this San Joaquin tiwal Health'.)'.strict. <br /> k - <br /> Home owner or licensed agent' certifies <br /> as to becomet b act ta-w kman s compensat on laws of California"tt <br /> -is issued, f shall"not-emplfly any person in 5 <br /> Contractor's hiring ar sub-cortracting signature certifies the following'."I-GertlfythaUn the performance of the work•forwhich.thls _4, <br /> permit is issued, I shall-employ, subject to workman's compansl3tion.lawa R►f:Californa." <br /> :- <br /> -"I will I for a ro i;lns ect' for to grouting and a"final inspeetlnR: <br /> i <br /> 1 L" Title: —Ata x <br /> Date: <br /> Signed X (Draw Plot Plan on Revers$ • • e) <br /> _ FOR EOART ENT USE ONLY <br /> PHASE I I. to <br /> f Application Accepted"By <br /> Additional Comments: �, h t l Inspect' n <br /> It Grout Inspection Date J,, "`��� <br /> Inspection By � ` - <br /> t. -Date IrispectioilOy Yt <br /> l.l <br /> '� 1"8 Received By January 31 ❑ July 1 &RBeeived By'July X31 <br /> Fee IS Due: ❑ ANNUALLY ❑'FEiit]NIT^' ❑.PER-SITE ❑ EACH w.,.`�"dtiriUOry REMIT <br /> REMITTANCE - E AMOUNT DUE CHECKED <br /> «BASE -:�:1-"EXPLANATION -DATE DATE REMITTED AMOUNT <br /> I fir <br /> i FEE <br /> LESS <br /> �. PRORATION <br /> PLUS Y <br /> i_ PENALTY <br /> Y <br /> OTHER f <br /> l <br /> i. OTHER; _ <br /> Delivered <br /> Received by Date Receipt No. <br /> PePermitPermitNo. ' -`" is andip Date Mailed <br /> .APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.BoK 2009 STOCKTON,CA 55201 <br />