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Applications Will Be Processed When Submitted Properly Completed. r?o i n__If7ionh""34pFOROFFICEUSE: APPLICATION' FIS# <br />144jff1i <br />For Non-Transferable, Revocable, pen able) PUM ELL <br />ENVIRONMENTAL HEALT- H`PE&y,M 'i 2 41982 <br />COMPLETE IN TRIPLICATE) WATER QUALITY <br />Application is hereby made to the San Joaquin Local Health Dlstrictforapermittoconstruct a r5r;in ttsw 1 <br />crl <br />9 <br />o i C. ribed.This application ismadeincompliancewithSanJoaquin County Ordinance No 1862 and the rules and regulatip t sfff4 ba9LGg i+4,QTExactSiteAddressfcal Health District.3/ 9 <br />City/Town <br />Owner's Name <br />Address eD r r Phone..6 a <br />CityContractor's Name w%r` w. License#" <br />L <br />4 <br />2 3 <br />Vis" <br />n 1BusinessPhone__'Contractor's Address 4 F e?Emergency Phone IIsCertificateofWorkman's_Compensation Insurance on File With SJLHD? Yes NoTYPEOFWORK (CHECK):NEW WELL DEEPEN RECONDITION DESTRUCTIONWELLCHLORINATION = WELL ABANDONMENT OTHER PUMP INSTALLATION 0 PUMP REPAIRREPLACEMENT <br />DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy iSewageDisposalFieldCesspool/Seepage Pit Other <br />Property Line Private Domestic Well Public Domestic WellINTENDEDUSE53TYPEOFWELL-- .— <br />INbUSTRIAL CABLE TOOL Dia. of Well ExcavationDOMESTIC/PRIVATE DRILLED Dia. of Well CasingDOMESTIC/PUBLIC DRIVEN Gauge of CasingIRRIGATION .x GRAVEL PACK Depth of Grout Seal <br />CATHODIC PROTECTION ROTARY Type of Grout <br />DISPOSAL E OTHER Other Information i <br />GEOPHYSICAL <br />Surface Seal Installed By: <br />i <br />PUMP INSTALLATION: Contractor <br />Type of Pump <br />PUMP REPLACEMENT: 0State Work Done <br />H.P. <br />PUMP REPAIR. r_ <br />State Work Done <br />DESTRUCTION OF WELL: Well Diameter Approximate-Depth <br />s 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 Countyordinances, state laws, and rules and regulations 6f 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 permitisissued, 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 forwhich thispermitisissued, I shall employ persons subject to,workman's compensation laws of California." <br />t' I will call for a Grout Inspection prior to grouting and a final inspection. <br />Signed XYh. r a ; <br />r Title: Date: J' <br />E Draw Plot Plan on Reverse Side) <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />W Application Accepted By <br />T`\ <br />Date q <br />Additional Comments: <br />Phase II Grout inspection hese III final fns actionInspectionByDateInspectionByDate —7`0— F4 <br />Fee Is Due: ANNUALLY '- PER UNfT- PER SITE - EACH - January 1 &Received By January$1 July 1 &Received-By•auly 37 <br />BASE - EXPLANATION BILLING . .REMITTANCE REMIT <br />DATE DATE REMITTED 4MOUNT DUE CHECKED <br />1 AMOUNT <br />FEE 4 b. <br />4T <br />PRORATION <br />t <br />PLUS y <br />PENALTY <br />OTHER . <br />OTHER <br />Received by Date Receipt No.: - Permit No I suan a Date - Mailed Delivered ...APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201