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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> l <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN 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 compliance)�ith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address "`. ` `. .s �? <br /> CitTown _ - -- <br /> Owner's Name .e,- .��" _ Pho Phone -� <br /> Address -1� ' <br /> �_.. City ��'�'- �� � - C5 <br /> Contractor's Name ,:� - f: J €" icense# Business Phone 1��t 1 <br /> Contractor's Address :( t" ' A, ,_ Emergency Phone �i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL&""' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERPUMP INSTALLATION ❑ PUMP REPAIR 11REPLACEMENT❑ t _,�'� <br /> DISTANCE TO NEAREST: Septic Tank 1. - Sewer _ Pit Privy <br /> Sewage Disposal Fiel.41 d _ Cesspool/Seepage Pit __ O1her <br /> Property LinePrivate Domestic WelL Public Domestic Well ` ' <br /> INTENDED USE TTy E OF WELL <br /> �i <br /> ❑ IN6TRIAL L,�,<A-BLE TOOL Dia. of Well Excavation j� �'- <br /> 9�-6OMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' _ <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 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 4�I f r a Gr ut Ins on p'onto grouting and a final inspection, <br /> Signed X Title: _ Date: '" 7 w <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By------_ Date . <br /> Additional Comments: <br /> Phase it Grout Inspection Phase III Final Inspection <br /> Inspection By _ Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE RET <br /> BASE EXPLANATION $ MI <br /> A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .� �\3 i �i� <br /> LESS ��' <br /> � -- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER --_ - -- <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is an Rate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />