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Applications Will Be Processed When Submitted Properly Completed. Be�ii r l��5{i�,nMeAppVaftfn. <br /> FOR OFFICE USE: APPLICATION U l. 1 <br /> (For Non-Transferable, Revocable, Suspend, <br /> 10 IgWQ <br /> ENVIRONMENTAL HEALTH PERMIT VCT PELL <br /> ,+ 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL N t <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or instalP*AtfF[gerSp3Tfff( V.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address `( . Z JVL.,T City/Town 63C QA o a- <br /> Owner's Name %A_1!'L RAI 493 -. <br /> Phone <br /> Address Vn City t)A,- <br /> Contractor's Namer{„n .Su > &Iv License# Q`[Z Business Phone- 835�-2a2o7 <br /> Contractor's Address J Al �G,1J n) ......_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes AM No r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 19 <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 Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> CiJ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout . <br /> ElDISPOSAL ❑ OTHER Other Information c i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ADb + <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof 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." i <br /> I will call f a Grout lnspe prior o grouting and a final inspection. <br /> Signed X Title: WfA ltd? Date: Ab — <br /> (Draw Plot Plan on Reverse Side) + <br /> F R DEP TMENT U O LY <br /> PHASE _ <br /> Application Accepted By X�vDate d' <br /> Additional Comments: <br /> Phase II Grout Inspection r9 Ph se I! Fina I. pection <br /> Inspection By Date Inspection By Date /,g/",S— <br /> Fee <br /> 0 "S~Fee Is Due: ❑ ANNUALLY ❑ PER UNIT U.:PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> 1 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ', DATE DATE REMITTED AMOUNT � <br /> FEE <br /> LESS <br /> PR09ATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> CD9 99 <br /> Received by Date Receipt No. Permit No. Issuance Date - 'Mailed'i- rEfelivered <br /> i !� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.NAZELTON AVE.,P.O.Box-20�991� STOCKTON,CA 95� <br />