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., . � <br /> Applications Will Be Pro�cessed When Submitted Properly Completed.Be S�l�YcS1l he Application. <br /> FOR OFFICE USE: <br /> APPLICATION', �� ti <br /> e. <br /> ,i <br /> (For Non-Transferable,Revocable,Suspen� t'} UMP& <br /> ENVIRONMENTAL HEALTH PER F^,,a,A � <br /> WATER QUALITY, Sa <br /> (COMPLETE IN TRIPLICATE) '' d i <br /> 'Y application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and <br /> nstal� �h rem.described.This <br /> made in compliance with S,A..0 Joaquin Coounty,Ordinance No. 1862 and he rules and regulations of the San Joaquin LLo it Health District. <br /> Exact Site Address �tyF �/ �/� ��' _ City/Town -r <br /> L '--a 9A. � ,"�S ate. Phone �w ? <br /> Owner's Name Cit <br /> Address y <br /> Contractor's Name License#,1 Business Phone" <br /> `-� Emergency Phone <br /> Contractor's Address: ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �_ No S <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION 11 a DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT C3t OTHER 11rP6MP 1P15T.ALLATION 11 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 Well Public Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL t Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED '- - Dia. of Well Casing <br /> ❑ DRIVEN 4 k Gauge df Casing <br /> El DOMESTIC/PUBLIC �. - x <br /> OPIRRIGATION ❑ GRAVEL PACK .. Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY it «„y Type of Grout <br /> IN <br /> ❑ DISPOSAL © OTHER Other Information <br /> E] GEOPHYSICAL i• +hSurface al Installed By: <br /> L� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I\s `{ P. I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 11 State Work Done <br /> PUMP REPAIR: - <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material-and Procedure <br /> I 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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, l shall employ persons subject to workman's compensation laws of California." <br /> I�w'itl��ali for a Grout spection prio grouting and a final inspection. <br /> r Signed X. a ..Title:. <br /> (Draw Plot Plan on Reverse Side) <br /> # � RIFP.R AENOUY <br /> PHASE 1 4 <br /> Date <br /> Application Accepted By <br /> Additional Comments: F <br /> k P se II Graut nsp tta r_ t a II Final Inspection <br /> Inspection By y N� Inspection By Date" <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN$T. ❑ PER SITE -❑,EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> S REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE s <br /> -LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ti <br /> OTHER <br /> OTHER <br /> t <br /> :Received mit by Date- Receipt No PerNo, Jss ante Dae MailedDelivered - <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE0MIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />