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I cr7s..t� �x{k},u�,.+'"^.'r,"ty���;,*iKka' '3R�'ta�* �. ea,'F�i1 't�+^"t!151r*.1:�`wt�ub�';rt.9r�y+r� 'S$"� "'•-�H�ua��c, ;�,�fa� :cs c. � -t'!F' �ra;:artFtic cx` , � r. , <br /> + +y� +'ts->s�1��" xA-ro y .'- :Y � - 5.7 f '.,;. rS -- •r��&.,."�.� P"-+0 RCE .. �" t r w' - <br /> { V.7. <br /> ;- t f,��.y. - `. 4 -e e',l .l <br /> ! <br /> _ 5t <br /> I e <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY H L)ISr ®CqL <br /> F , Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein fticied.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and theulasand regulations of the San Joaqui��al Health District. <br /> Exact Site Address -� ► City/Town _ <br /> Phoneme Lea 92- <br /> Owner's Name <br /> � Address _ �fl� City -�Ti�/'� <br /> Contractor's Name , License#3 Business Phonel +/ <br /> Contractor's Address y do-vt e*,, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTIONS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION K. PUMP REPAIRE] <br /> 4 + REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <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 /> P1 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 4 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r <br /> i ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> + PUMP INSTALLATION: Contractor Alir <br /> IF Type of Pump_ (,l �� .� -H_P. � <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I 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 /> ` <br /> Homeowner or licensed agent's signature certifies the following:g g g:"1 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 wtll all for a Grout Inspection nLior to grouting and a final inspection. <br /> i <br /> Signed X _ Title: Date:.,. <br /> (Draw Piot Plan on Reverse Side <br /> I� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> j. Application Accepted By 1� � � Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection hale III Fi al Inspection <br /> Inspection By Date Inspection By ate <br /> FFF� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 El July 1 &Received By July 31 <br /> ' { BILLINGREMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE AMOUED <br /> NT <br /> a y <br /> FEE ��� �S <br /> 1 LESS <br /> i� 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 95207 <br />