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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> lif (For Non-Transferable, Revocable, Suspendable) �� <br /> � Pl1MP&WELI. , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 1,N TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in comp ll,iance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San a uin Local Health District. ( <br /> Exact Site Address G, Eli g City/Town f _n- 1 <br /> Owner's NameI��z,�-4� 'p/ �'98d1 Phone t i <br /> Address (. du S1 ��. f�'� City <br /> I <br /> Contractor's Name Ca- u,0PLicense# ����- Business Phone <br /> Contractor's Address t ' � Emergency Phone <br /> Is Certificate if Workman's CompensationIns rance on File With SJLHD? Yes _ No <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 _ C` Seyver Lines Pit Privy <br /> Sewage Disposal Field pAD fl f _ Cesspool/Seepage Pit Other i <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I <br /> fDOMESTICl /PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ;�G <br /> RIVEN Gauge of Casing <br /> El IRRIGATION RAVEL PACK Depth of Grout Seal j <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f a <br /> E] DISPOSAL ❑ OTHER Other Information {ar_i� \ y_ypfr <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �G✓a�a <br /> PUMP INSTALLATION: Contractor �Jl <br /> 1� <br /> Type of Pump H-P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done O <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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, s <br /> Home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit 1 <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 cal fgr a Grout InSpSFt?' n prior to grouting and a final inspection. <br /> Signed X Title: Date: , <br /> ( w Plot Plan on Reverse Side) <br /> li <br /> FOR DEPARTMENT USE ONLY i <br /> i- PHASE I <br /> Application Accepted B I A � Date <br /> Additional Comments: <br /> it Phase II Grout Inspection Phase III Final Inspection <br /> Inspection Date Inspection By Date <br /> l Fee ISI'Due: ❑ NNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedlBy July 31 <br /> I REMIT. <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE CHEC ED <br /> i <br /> DATE DATE REMITTED <br /> AMOLINT, i <br /> FEE lip <br /> LESS <br /> PRORATIO <br /> PLUS s't <br /> PENALTY J <br /> •r <br /> OTHER�i I <br /> i d / ✓ ,C, / l <br /> OTHERt , <br /> ! <br /> i o a-7l41 <br /> Received by Date Receipt No, Permit No. IssUaiice.Date Mailed Delivered <br /> I <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSEAV{CES 1601 E.HAZELTON AVE.,P.O.Box-2009 STOCKTON,GA 95207 <br />