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Applications Will BeProcessedWhenSubmitted ProperlyCompleted. Be'sureTo51 n jTheApplication. <br /> tV <br /> J ; <br /> .4 0 <br /> fF,ft-0Fr10E USE: 16 +M APPLICATION 0 0 1980 <br /> d <br /> S <br /> bl <br /> R <br /> bl <br /> f <br /> T <br /> N <br /> (For Non-Transferable, Revocable, uspenable <br /> 6��e �AN Jn:". ,,ypJ P�ynnf&WELL <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH- <br /> /go �� � <br /> DIS RIOT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address 6 -r(,, C MAIC :577City/Town �i047//f <br /> Owner's Name �� L� Phone �O <br /> Address iT /AACity �1 <br /> Contractor's Name /f��D�(, �.f &Zf 77 .14 lA(Cj License#53709' Business Phone -77 <br /> Contractor's Address PQ Oill 3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__XNo <br /> TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 'Z5— Sewer Lines fro Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line A;W Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ .INDUSTRIAL CABLE TOOL Dia.:of Well Excavation �� _ 41&57 Z.) <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1/10 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _� iS�C'� C�E�89E�lTQ�!7— <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 n <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 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 /> I will call for a Grout Inspection prior to grouting and a.final inspection. <br /> Signed X .� 1J� n k Title: Date: I �� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Applicati n Accepted By Date <br /> �Addi!' al Comments: <br /> P Grout speCtion �i Pha e l Final In ection <br /> tr-fnspection By Date _ inspection By �� ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER l ❑ 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 /> �6 1Y D <br /> Received by Date Receipt No. Permit No. I uance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br />