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ppncauansWill.Be Processed When Submitted Properly Completed. r ° 9►ijhA <br /> FOR OFFICE USE: �1 APPLICATION 1rr C'&x+on. <br /> (For Non-Transferable, Revocable, Suspendab <br /> ENVIRONMENTAL HEALTH PERMIT 28 ,98, <br /> WELL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY SAI, <br /> !� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/ori�� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JgAie,4604t'd <br /> til <br /> . This application is <br /> Exact Site Address �� ]"Health Dis#rict. <br /> Owner's Name City/Town <br /> If— <br /> Address Phone <br /> Contractor's Name 01 City <br /> Contractor's Address License usi - Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDmergYes Phone <br /> TYPE OF WORK (CHECK); NEW WELL Yes No - _ <br /> WELL CHLORINATION ❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIOpN�❑ <br /> l REPLACEMENT❑ WELL ABANDONMENT ❑ OTHER ❑ pUMp INSTALLATION C <br /> d <br /> DISTANCE TO NEAREST: Septic Tank +� PUMP REPAIR 11Sewer Lines �j <br /> Pit Privy Sewage Disposal field <br /> Cesspool/Seepage Pit <br /> Property Line Private Domestic Well S� Public Other <br /> INTENDED USE -� c bomestic Well <br /> TYPE OF WELL <br /> MOM <br /> CABLE TOOLTI)OMESTIC,/LPRIVATE Dia. of Well Excavation �r <br /> 11DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing `r <br /> i ❑ IRRIGATION ❑ DRIVEN Gauge of Casing <br /> 13GRAVEL PACK Depth of Grout Seal <br /> 13 CATHOi?lC PROTECTION <br /> 11DISPOSAL 11 ROTARY <br /> ❑ OTHER Type of Grout ow <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor 1 41,111 <br /> PUMP REPLACEMENT: Type of Pump <br /> ❑ State Work Done H P <br /> PUMP REPAIR: ❑ <br /> DESTRUCTION OF WELL: State Work Done { <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 certif that in the Performance of the work for which this permit <br /> is issued, I shall not em to an g g' y p '1 <br /> P y y 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 /> ng <br /> I Will call for a Grout Inspection pi! to grouting a final inspection. <br /> Signed X <br /> Title: <br /> { (Draw Plot Plan on Reverse Side) Date: .. .Z - X <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By- - <br /> Additional Comment : Date <br /> Phys r Inspection, <br /> Inspection B Date ( Phb F I Inspection <br /> Inspection B <br /> Fee Is-Due: ❑ Date <br /> ANNUALLY ❑ PEA UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1&Received By January 31 ❑ JUI 1 & <br /> BASE BILLING Y Received MJ July 31 <br /> EXPLANATfON REMITTANCE g REMIT - <br /> DATE DATE REMITTED AMOUNT DUE CHECKED 4 <br /> FEE > AMOUNT <br /> ` <br /> PRO t <br /> f eb O <br /> PRORATION O <br /> PLUS <br /> PENALTY <br /> OTHER' <br /> OTHER <br /> Received by Date <br /> Receipt No. Permit No. <br /> APPLICANTy„RETURN.ALL COPIES TQ�ENVIAONMENTAL HEALTH PERMIT/SERVICES Issuance Date Maitetl <br /> Delivered J <br /> €J . - - - 9607 E.HAZELTQN AVE.-O.D.n..,.�n..e �___._____ <br />