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Applications Will Be Processed When Submitted Properly Corn Y E"0 SS�n Ile Ppf n <br /> FOk0FFitE USE: APPLICATION YY <br /> (For Non-Transferable, Revocable,Suspendabl ly! <br /> +YY 0 1680 <br /> ENVIRONMENTAL HEALTH PKRMITSAN n P WELL O <br /> COMPLETE fN TRIPLICATE WATER QUALITY j��f "Z ._,u!?IN <br /> Application is hereby made to he San Joaquin Local Health District fora permit to construct an1tP Ea�IltthE*9rNbvCi,[t�fescribed.This application is 1�7 <br /> uL1 <br /> made in compliance wit S J qui fg�'n r o. theland r ulations of the Sari J aqulncal, eal D'stric <br /> t. r <br /> Exact Site Address �t 0 City/Town �& <br /> Owner's Nam 09Z.-a" =7— Phone <br /> Address City <br /> Contractor's Name UMLicense Busines Ph o e <br /> 47 <br /> �} <br /> Contractor's Address 7- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes . 11� No <br /> TYPE OF WORK (CHECK): NEW WELLG�' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMEIy,T 1:1 OTHER ❑ PUMP INSTALLATION �G PUMP REPAIR❑ <br /> REPLACEMENT 13 / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /" Pit Privy <br /> } <br /> Sewage Disposal Field Cesspool/Seepage Pit Other � <br /> Property'Line'= Private Domestic Well —'Pbblic Domestic Well u k <br /> INTENDED USE TYPE OF WELL f �� <br /> ri <br /> ❑ II DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1got <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ! <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 13 R�GG�RRAVEL PACK Depth of Grout Seal <br /> 1:1 CATHODIC PROTECTION It� OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other'Information � <br /> ❑ GEOPHYSICAL , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 5 r <br /> Type of Pump H.P. # <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County E <br /> ordinances, state laws, and ruies 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 .-X <br /> is issued, I shall n ploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contrac or sub-contra ' signature certifies the following:"I c that in the performance of the work for which this <br /> per rt i I hall mploy perso s subject to workman's compens I Paws of California." <br /> I ill c spectio No o grouting and a final inspect! y <br /> Date: <br /> Title: <br /> Signed X <br /> T_ '(Draw Plot Plan on Reverse Side)— <br /> r <br /> FOR DEP RTMEN ;USE pNLYPHASE I Application Accepted Byd Date <br /> Additional Comments: —All 40 <br /> Phase II Grout Inspection Phase III Final Inspection I <br /> Inspection By Date Inspection By-)V4" `00-4— Date Z-3 -FJ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT V'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 /> FEE <br /> LESS <br /> PRORATION <br /> PLUS # <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> Received 6y Dale '' ¢ 4 Receipl No. Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1 01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />