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Applications Will Be Processed When Submitted Properly Completed.B ur�dr$Ig�tiT 11 DWELL <br /> FOR-O.IXicE USE: APPLICATION [��;.f �!�d� 115 <br /> (For Non-Transferable, Revocable,Suspen ) _ Ur E <br /> NVIRONMENTAL HEALTH PERMIT OCT 9 197 <br /> (COMPLETE IN (PLICATE) WATER QUALITY �nnt� t�1 l ��+nr <br /> Application is hereby madetotheSan Joaquin Local Health District for a permit toconstructand/orirl�heuvbr>�i�r��rCriTde�Crf6f.This application is <br /> made in compliance with oa uin�gugty tnance No. 1862 and tll�ruJes and regulations of M�gPt4151alth i iii, <br /> Exact Site Address r City/Townes /'Jf <br /> y� ��'� !Jr ,$ Phone_ J1 <br /> Owner's N me -� <br /> Address ' City <br /> Contractor's Name Li ens #' 3 Busin ss Phone <br /> Contractor's Address <br /> X410' Emergency Phone _r/9 d3� <br /> _ '_` j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .. No CZ- �"� d�44 t <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTIONN D <br /> WELL CHLORINATION El WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION !� PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ON-.— <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther 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 r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth'of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �� Surma Seal Inst lled By: <br /> PUMP INSTALLATION: Contractor U S <br /> Type of Pump P' <br /> PUMP REPLACEMENT: &State Work Don <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure~ <br /> i 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 /> 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." <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 i sued, I shall em Icy persons subject to workman's compe laws of California.,' <br /> Grout nspectt In prior to grouting and a final inspe I. <br /> Signed ` Till Date: <br /> g / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTME T USE ONLY <br /> PHASEI Q <br /> Application Accepted By Date / <br /> Additional Comments: <br /> Ph se I Grout Inspection Phase III Final Inspection <br /> l Inspection By. Date .Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER S$TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7- <br /> XReceived by Date-- Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 9520 <br />