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A ctions Will Be Processed When Submitted Properly Completed. Be S r K'fo%n`'fh�eApJ'icMioL j <br /> OR OF*ICE USE: �U*? 3ra�-y� APPLICATION <br /> l (For Non-Transferable, Revocable,Suspendable) <br /> EN �I <br /> AKP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �� j6 <br /> l I <br /> ' t � <br /> (COMPLETE IN. <br /> TRIPLICATE) - WATER QUALITY HEALTH 4�c�LOCAL <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herePlAIRL"..This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sanquln Local Health District- <br /> Exact Site Address �q i^ 0 City/Town �IC JLoh <br /> I 2 i <br /> Owner's Name Phone <br /> F <br /> Address ' City Q <br /> Contractor's Name �h License# )5-!q?— Business Phone <br /> Contractor's Address I 5�33Emergency Phone "�6y l - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No .K a4c)w amv i6lop Y <br /> TYPE OF WORK (CHECK): NEWrWELLX 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 /> T- Sewage Disposal Field Cesspool/Seepage Pit Other �1 <br /> Property Line Private Domestic WeII.�Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia- of Well Excavation ! �9 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing J0 9A r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal G70 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout o� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �" f ��► <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Aproximate 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 /> 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 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." <br />' I will c II or a Grout Irilstpeclion c to grouting and a final inspection. <br /> !>e✓/ :/' <br /> f Signed X Title: Date: <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> a H Gr ut Inspection Phase Ill Final Inspection _ <br /> Inspection By Date G �f R. Inspection_By - �� Date S ~�- <br />' Fee Is'Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received ay January 31 �❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> IAMOUNT <br /> FEE L13 -s'14,3 <br /> LESS <br /> PRORATION <br /> L PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />