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Applications Will Be Processed When Submitted Properly Completed SejSure To Sign,The Application. <br /> FOR OFFICE USE: APPLICATION; 1 <br /> (For Non-Transferable, Revocable,Suspendable) &WELL <br /> ENVIRONMENTAL HEA TH PERMIT' _ C -!„-?fin <br /> y <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Disirict fora permit to constriCal<ah8/_drib"stall theW0r therm described.This application is <br /> -�d wf <br /> made in compliance wl�i San Joa I o_unty O nance No. 1862 and the rules and regG{ati6,6siq -this Sark' ggun L al eaith District. <br /> Exact Site Address �l City/Town /d"� T�i,— <br /> Owner's Name �-� Phoned-� 3 9 7C X <br /> Address r City <br /> E % 1 <br /> Contractor's Name License#�Is x-37 2 Business Phone <br /> Contractor's Address j, f L - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _}� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,_,/ } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER C1 PUMP INSTALLATION El PUMP REPAIR L�J <br /> REPLACEMENT❑ <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ 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 urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor c� <br /> Type of Pump� �' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: O'State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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, 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 California." <br /> Contractor's hiring orsub-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 for Grout Lection prion to grouting and a final insjCtion. 7 J <br /> Signed X / Title: L�,/ Dale: C J_ <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> �`��^ - ©� Date <br /> Additional Comments: <br /> Phase II Grout Inspection P as III FlIpal Inspection <br /> Inspection By Date Inspection By Date O <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> O t"� <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 � v <br /> Received by Date Receipt No. - Permit No. Issulance Crate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />