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Applications Will Be Processed When Submitted Properly Completed. 8tptJrea0wgm-+me-Appimm"onl I I I <br /> FOR OFFICE USE: APPLICATION f� ( t1�9 ill <br /> - (For Non-Transferable, Revocable,Suspendle APR 2 19�gmp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SA'' `� `' <br /> (COMPLETE IN TRIPLICATE) } �°t I IS�R1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or insta I k hl a in escrI ed.This application is 3i <br /> made in compliance �'t -Sar1 Joaq nf.�,ount,-fdltin nca N9. 1862 and t rules and regulations of the San Joaquin Local Health District. HCl <br /> Exact Site AddressVv�g .__T5•-, A)t G UE City/Town G�THgbp <br /> Owner's Name L- lL1�C- Phone s <br /> Address - a <br /> City r ��P [.r�oGZlVrfa <br /> Contractor's Name _ KL�tN —LpESS- License# Business Phone 3 5 <br /> Contractor's Address �B�S C ' T" Emergency Phone <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 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1+ <br /> Property Cine Private Domestic Wei1.�. Public Domestic Well <br /> "TYPE OF WELL � 't <br /> INTENDED USE <br /> jO�NDUSTRIAL CABLE TOOL Dia. of Well ExcavationOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r— <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal F�lT <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout T <br /> - ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: '—�� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> It <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 sinal inspection. <br /> III Signed X �J- L 1�4DE� S Title: Date: ll 161c� <br /> ' — raw Plot Plan on Reverse-Side)r <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I •� 7.(O <br /> Date <br /> Application Accepted By <br /> Additional.Comments: <br /> Phase II Grout Inspection se 111 Finai Inspection <br /> Inspection By Date Inspection B Date <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Receiv d By REMITuly 31 <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> F� l <br /> FEE yl <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> ( <br /> E OTHER <br /> - � Date � � Receipt No. Permit Nom. � uance Date Mailed Delivered,,.i'` r �. <br /> f +� Received by r ' <br /> APPLICANT—RETURN ALL COPIES TO:'"�ENVIAONMENTA1 HEALTH PERMnVICES u 1601 E:HAZELTON AVE.,P.O.Boz 2909 STOCKTON,CA 95201 <br />