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Applications Willi Be Processed When Submitted Properly Completed. Be Sur�l Ilriatit/n. T <br /> FOR OFFICE UME: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) MAY 2R qqq <br /> ENVIRONMENTAL HEALTH PERMIT `�'UhA WELI <br /> -03 <br /> (COMPLETE—IN f (COMPLETE IN TRIPLICATE SAN JOAQ1 (N f+ <br /> } �L;d'.`"�53�5"-S'�E��„J -WATER QUALITY F6f �...; v, OPAL <br /> Application is hereby made to the San Joaquin'Local Health District fora permit to construct and/or install the wlols'I'te�+3ihserlbl Tris application is <br /> made in compliance,vyith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_�of;. -c r 1 a. - u "�AiJ r�.v �+ � "ate City/Town F `� .•) <br /> Owner's Namem7 Phone -�^ � / <br /> Address �"] : ����� t! A) City <� f�40of O <br /> Contractor's Name `� &VII Sulr�►csLicense#rM/1 Business Phone 0RO-1207 <br /> Contractor's Address �c�� v �r rw Emergency Phone I- <br /> Is <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 El PUMP REPAIR f <br /> REPLACEMENT M f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seewg <br /> Pit Other <br /> .Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL '❑ CABLE TOOL Dia. of Well Excavation- <br /> f 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ..f <br /> ❑ DOMESTIC/PUBLIC. ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION — -❑ ROTARY R 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 -P k^+-+-0U-C ��T [a � <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:"!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," +R <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 pe sons subject to workman's compensation laws of California." <br /> I wl all for a ut ecti rior to grouting and a final inspection <br /> -57 <br /> Signed X ` Title: .Z, e z.. ' <br /> Date: - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �n Date ��U <br /> Additional Comments: <br /> Phase II Grout Inspection nal Inspection <br /> Inspection By Date Inspection 2��_ DateFee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 & By Ja uary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED ; <br /> tI AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date .. Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />