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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Thet—M <br /> ppliC16ori:9 <br /> g , <br /> FOR OFFICE USE: APPLICATION ' <br /> UU <br /> (For Non-Transferable, Revocable Suspendable) P &wf i3 - � <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) -WATER QUALITY i _ t' NN LOCAL <br /> vjrtl p. F , <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or,install the work herein de lrib6d.This ppfi a 01US <br /> made in compliance witq San Joaquin tunty Ordinance No. 1 2 d the rules and regulations of the San aquin LcIIHealth District. <br /> Exact Site Address y` City/Town <br /> Owner's Name A USOtJ Phone- <br /> Address DW4 IZDSi ,:•;r. .City 0ACDA- <br /> Contractor's Name i iv '. License# Business Phone'"YPJ�M �2r'� •' - ` <br /> Contractor's Address - , "' �''' '� ' Emergency��Phon�e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? _Yes ' �11No <br /> TYPE OF WORK (CHECK): NEW WELL❑�" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - WELL-ABANDONMENT ❑ OTHER ❑. PUMP INSTALLATION ❑ PUMP REPAIRS <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 t Public Domestic Well f <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL- N ❑ CABLE TOOL — Dia.-of Well Excavation ---- _ - I <br /> 04 DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1:1 GEOPHYSICAL Surface-Seal Installed By: N <br /> PUMP INSTALLATION:' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: " ❑ State Work Done5 <br /> PUMP REPAIR: A <I 4 State Work Done u w F' � <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 Heaith District. _ a <br /> Y <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance ofthe work for which this permit <br /> is issued, I shall not employ-any person ih 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 forwhich this <br /> permit is issued, I shall employ-persons subject to workman's compensation laws of California." g.� <br /> I wil II for a Grout Insti or to grouting and a final inspect'o J <br /> Signed X Title: !I ; Date: L � <br /> i 1 " (Draw Plot Plan on.Reverse Side) <br /> FOR DEPARTMENT USE ONLY t, <br /> PHASE I r1 <br /> Application Accepted By Date <br /> Additional Comments: I - <br /> Phase It Grout Inspection _• rt se II Final Inspection <br /> Inspection By. IWzl Date 7 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLYPER UNIT ❑ PER SITE ❑_EACH'.- <br /> ❑ January 1 B Received By January 31 '❑ July.1 &Received By'July 31 <br /> REMIT <br /> BILLING REMITTANCE q $ R <br /> BASE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ° <br /> PRORATION t 1' <br /> PLUS _ wI IJ I <br /> PENALTY <br /> OTHER '$ <br /> i' <br /> OTHER <br /> 93,-ate [ <br /> -Received by - -- DaS! - Receipt No, - Permit No. - - Issuance Date - --Mailed - - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCI(TON,CA 95201 +� <br />