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FOR OFFICE USE: / APPLICATION <br /> h,K (For Non-Transferable, Revocable, Suspendable) PUhAP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE) WATER QUALITY <br /> pplication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> f xact Site Address SO"r`?� ;!r. I!� _ r eci^y� .j' . CI- City/Town �® <br /> Owner's Name �u n' 5 a" Phone ir� <br /> Address ..�7 ��.X '� t�67 iCS Sk� Gw6r; ..( ,('l.1 r f�i .4` E�t l;/!r/ _City <br /> Lontractor's Name c-71` / + .. fir. License N /Q ?a�.(l Business Phone -(r ;i ` -;v,7�<^ <br /> ontractor's Address Ltnay L� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes a No <br /> -YPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ElPUMP INSTALLATION ® PUMP REPAIR❑ �J <br /> EPLACEMENT❑ 1 <br /> _DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �)1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t, <br /> `. Property Line Private Domestic Well Public Domestic Well UJ <br /> INTENDED USE TYPE OF WELL <br /> 73 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> U DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal —17 <br /> D CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1,-0 DISPOSAL ❑ OTHER Other Information (\ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> SUMP INSTALLATION: Contractor `":-+�-s.J a /r` ',r. <br /> *A Type of Pump 'Tu ✓ ala rnG H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> SUMP REPAIR: ® State Work Done ,` IR - - ° <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ar <br /> 1 .. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> R 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 cerlifiesthe following;"I certifythatin the performanceof thework forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ll for a Grut ectionpner-tvArouting and a final Inspection. <br /> yy �rrt�} ! <br /> 1 "c ,I _ <br /> Signed X AvJ ,. - :....--.. wL- .ii j4ee J Dale: / :iO C' <br /> `► f <br /> (Draw on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date�/�) ' (L),j�l•(,(. <br /> Additional Comments: <br /> s Pha. _ sg 11 Grout Inspection h s III Final Inspection <br /> Inspection By Date Date Inspection By✓� Date - <br /> Fee <br /> ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C <br /> LESS <br /> y PRORATION <br /> PLUS <br /> {{ PENALTY <br /> OTHER <br /> OTHER <br /> z- <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.aoa 2009 STOCKTON,C - 201 — <br />