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Applications Will Be Processed When Submitted ProperlyCompleted. 6e Sure tosign 1newppn uqn <br /> FOR, FICE USE: s APPLICATION <br /> rr (For Non-Transferable, Revocable, Suspendable) <br /> I'L1MP&WELL " <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto constructind/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San�C a <br /> oaaquin Local Health District. <br /> Exact Site Address I tirm9n ?4y/Town p <br /> 15-3882 <br /> S Owner's Name sRi ZT slim Phone <br /> Address City <br /> P Contractor's Name License# 9] 3646982 e <br /> Contractor's Address 13233,_Rardan Rd Hd - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? t'9e Tri 10 `da'`'t No <br /> n' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ -� ; <br /> DISTANCE TO NEAREST: Septic.Tank 17�♦ Sewer Lines Pit Privy <br /> E Sewage Disposal Field Cesspool/Seepage Pit 11 Other <br /> Property ne Private Domestic Well 300 Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL — - 12" t0 50 f t� 10" -t0 200 <br /> 1:1 INDUSTRIAL .J0 CABLE TOOL Dia. of Well Excavation <br /> ..W DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> l ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing •� W �1 <br /> ❑ IRRIGATION ❑'GRAVEL PACK Depth of Grout Seal �Ft <br /> E] CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 Sk• cement grout <br /> © DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface S a installed By: con <br /> t `"CtO <br /> PUMP.INSTALLATION: Contractor =— - <br /> k Type of Pump H.P. j <br /> t <br /> PUMP REPLACEMENT: i ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ti <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t _ <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. �1 <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 or sub-contracting signature certifies the following:"I certify that in the performance of the work torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II or a Grout spection prior to grouting and a final inspection. <br /> (, Title: Date:Z. <br /> X ' <br /> Signed <br /> (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I .�_�. <br /> Application Accepted By - Date <br /> Additional Comments: <br /> se.tH 41ection <br /> has I Grout InspectionInspection By Date Inspection By `/12 <br /> � ' °(� <br /> S Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1 ❑ July 1 &Recel etl y July 3 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> rPRORATION .. <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER <br /> Received by I Date Receipt No. Permit No.: .� F Issuance Date - ,Mailed .Delivered <br /> ;. APPLICANT—RETURN ALL COPIES TO:.. ENVIRONMENTAL HEALTH PERMITISERVICES *1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />