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FOR OFFICE USE: <br />t <br />EXPLANATION <br />8ILLING , <br />REMITTANCE. <br />$ . <br />I Nr:Non-Translerable, Revocable, Suspendable) ,f <br />REMIT <br />CHECKED <br />?' <br />DATE <br />DATE <br />REMITTED <br />ENVIRONMENTAL HEALTH PERMIT <br />AMOUNT <br />FEE <br />r <br />Ot <br />'! <br />LESS <br />(COMPLETE IN TRIPLICATE) <br />WATER QUALITY' ., <br />fkfibeaa <br />Application is hereby matleto the San Joaquin Local Health ibis rict fora permit to constructandAminstalI the work <br />r <br />made in compliance wi h an <br />i County dinanc N . 1862 and the r}�R d regulations of the San in I 1 lcl. <br />��j <br />PLUS <br />Exact Site Address <br />1 City/Town <br />Owner's Name <br />Phone <br />Address <br />City <br />Contractor's Nam <br />Cr tf "License If��2igc Business Phone <br />Contractor's Address z .( Emergency Phone j �-� <br />NA <br />_ <br />Is Certificate of Workman'sjCompensation Insurance on File With SJLHD? Yes No: <br />OTHER <br />TYPE OF WORK (CHECK): <br />WELL CHLORINATION El'' <br />NEW:WELL ❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTIO,N 13Q <br />-WELL `ABANDONMENT 13m'.•OTHER ❑"' PUMP .INSTALLATION l t PUMP REPAIR❑ <br />REPLACEMENT ❑ <br />DISTANCE TO NEAREST: <br />Septic Tank...:Sewer Lines Pit Privy <br />} <br />Sewage Disposal Field Cesspool/Seepage Pit Other <br />"" <br />P.roperty Line Private iDomostic Well Public Domestic.Well _ <br />INTENDED USE <br />TYPE:Ot=.WELL-- <br />❑ INDUSTRIAL "` <br />fl CABLE,.TO.OL .., Dia, of Well Excavation <br />❑ DOMESTIC/PRIVATE <br />❑ DRILLED Iiia .of Well Casing <br />❑ DOM DTIC/PUBLIC .. <br />_ <br />❑ DRIVEN Gauge of Casing <br />a RRIGAT10N <br />❑ .GRAVEL PACK Depth.of Grout Seal <br />❑ CATHODIC PROTECTION <br />❑ ROTARY Type of Grout <br />El - DISPOSAL <br />© OTHER Other Information <br />❑ GEOPHYSICAL <br />:.. Sur fa eal Installed By: <br />_ <br />z PUMP INSTALLATION: <br />Type of �mp' C/ or!? . <br />PUMP REPLACEMENT: ❑ State Work Done <br />PUMP REPAIR: ❑ State Work Done <br />DESTRUCTION OF WELL: Well Diameter <br />H.P. <br />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 Cotmly <br />-ordinances, stale laws„and rules and regulations of the•San-Joaquin Local Health Districtor- <br />Home owner.or licensed agent's signature certifies the following. '.1 cert0y:that in,Qiye performance of the work (orwhich this pel41111 <br />is issued, -1 shall not employ any person in such manner as to become subject to workman's compensati orr- laws of Californ�i ” <br />Contractor's hiring or sub-contracting,signature certifies the following: 4'1 certify that irrthe,performance of the work for which This <br />permit is issued,..) shall employ persons subj CIAO. orkman's rom—pensatiogiIaws of California:' <br />I I all for Gr trt Inspection prior g utin nd a final Inspec 9 <br />Signed X C J� Title: ! Date: <br />-` (Draw Plot Plan on Reverse Side) <br />PHASE <br />Application Accepted By <br />Additional Comments:— <br />. Phase it Grout lnspeclion <br />lnspection,,By Date _ <br />FOR.DEPARTMENT USE ONLY <br />'. /. / r� <br />Date 1..1 <br />-Phase III Final Inspectio/ <br />Inspection By T.P Fate -2 ! <br />Fee Is Due. 0 -ANNUALLY ill PER UNIT ❑ PFR SITF 1-1 FARF! 171 ice.. —', i r'i ,..�.. v �......:.._� o..-i,......,� <br />- <br />BASE ., <br />EXPLANATION <br />8ILLING , <br />REMITTANCE. <br />$ . <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />?' <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />r <br />Ot <br />'! <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received ny - Date Receipt No. Permit No. Issuance Date -Mailed - 'Delivered ' <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZF.LTON AVE., P.O. Boa 20o9 STOCKTON. CA 95261 — <br />t, <br />