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FOR OFFICE USE. APPLICATION W i� t, ' <br /> (For Non-Transferable,Revocable,Suspendable) &WELL ` <br /> EN 'IES 7YIR�NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUAiI.TT <br /> A lcationisherebymadetotheSanJoaquinLocal HealthDistrictfor apermittoconstructand/orinstaflthework heral�6&riipff@@Ap <br /> in compliance with San Joaquin County Ordinance No.1882 and the rules and regulations of the San Joaquin L r <br /> Exact Site Address £ Ci4rrrown k f>Si i C;` .` I i <br /> SVG ..-� Phone T <br /> Owner's Name - <br /> Address , City- <br /> Contractor's Name License p Business Phone_ <br /> Contractor's Address Pt 11,V If-27 l 4� 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 /> Property Line Private Domestic We11 Public Domestic Well 01 <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation — <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> E DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY 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: ❑ e Work Dane <br /> PUMP REPAIR: State Work Done <br /> r'TRUCTION OF WELL: Well Diameter Approxirr►ate 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 i <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Horne owner 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 planner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sutrcontracting signature certifies tine following:"I certify that Iry the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California.- <br /> I will call for a Grout Inspec lion prior to grouting and a final Inspection. <br /> Signed X Title Date:.{ <br /> (Draw Plot Plan on Reverse ide) 47 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By On Date t`—SA <br /> Additional Comments: <br /> Phase 11 Grout Inspection : n s action <br /> Inspection By tate Inspection ay Date <br /> Fee Is Due:❑ ANNUALLY Q PER UNIT ❑-PER SITE ❑ EACH ❑ ,fanuary 1 f Reoetvw By January 31 ❑duty 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE i AMOUNT DUE CHECKED <br /> BASE EXPLANR1iON DATE DATE REMITTED <br /> AMOUNT <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Re11e3pt Nle PeMit PLO_ to 1i NlaileA Delivered <br /> APPLICANT—RETURN ALL COPIES T* ENYIn)NINErAL#GAL-W FEii,WA tM E MAZELTON AVE-P.O.6e1 2009 STOCKTON,CA 95201 <br /> t <br /> i <br />