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Applications Will Be Processed When Submitted Properly Completed. Be SureToSia ,TheApplication. ,„ v <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 1 <br /> PI11U�d& ELL <br /> ENVIRONMENTAL HEALTH PERMIT 1/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 01 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ' San Joaquin.Cougty O dinance No. 1862 and the rules and regul tions of the San i Local Health District. <br /> 04n,rFitdress C9City/Town s me Phone / { <br /> E� City_ <br /> Address ti <br /> Contractor's Nam L " License(p0 g�� Business Phone ys g <br /> Contractor's Address Emergency Phone F <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ar No 6 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®r.PUMP REPAIR❑ <br /> REPLACEMENT❑ S <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �-'Q�— fit <br /> Sewage Disposal Field Cesspool/Seepage Pit Other —�' `• <br /> IProperty Line ---I Private Domestic Well ^^ Public Domestic Well <br /> INTENDED USETYPE OF WELLt, 114 <br /> ❑ INDUSTRIAL rDRILLED BLE TOOL Dia. of We. Excavation l ; , <br /> a- MESTIP PFRlVAT E Dia. of Well Ca ingr❑ DOMESTIC/PU.BLICIVEN Gauge of Casing 1 <br /> ❑YIRRIGATION�� ❑ GRAVEL*PACK Depth of Grout Se ��•. '` �' <br /> CATHODIC PROTECTIONy �i�OTIARY, Type of Grout <br /> DISPOSAL' ❑ OTHER Other Information <br /> Surface Seal Installed By: �— r'E �_, t /�`C = <br /> ❑"GEOPHYSICAL `T <br /> PUMP INSTALLATION: Contractor <br /> .. .� .� Type-of ump H.P. <br /> r. a •- <br /> PUMP REPLACEMENT; -.P-State-Work Done - t <br /> I � <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: g1, rWell Diameter PP P <br /> rDescribe Material and rocedure <br /> f( F. i <br /> I hereby certify that l have prepared this application and thatretnWork will be donesiri,accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin LobalrHealth District; fi <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 /> is issued, I shall not employ any person in such manner as to become subject to--workman's compensation laws of California." R_ <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a G I n p 'or to routing and a final inspection. <br /> Si �.. Title: �1W=4SI <br /> (Draw Plot Plan on Reverse Side) t <br /> g <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By d °"^ Date 79 <br /> Additional Comments: <br /> a e II Gr ut Inspection hase 11 Final Inspection <br /> Inspection By <br /> Date �? Inspection By Date <br /> Fee Is tfue: ❑ ANNUALLY ❑ PER UNIT 15 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 $ <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ; <br /> DATE DATE REMITTED AMOUNT <br /> L � d <br /> FEE Lr.- • <br /> LESS <br /> PRORATION - <br /> # I <br /> PLUS € ,, <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER �� t <br /> `79 117 1d/1gI-79 <br /> _ _Date _ -Receipt No-. _ Permit No. 9 Issuance Date Maned Delivered <br /> PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - �, 1601 E.HAZELTON AVE.,P.O.Box 200 - STOCKY. ` 1 J <br />