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Applications Will BelProcessed When Submitted Properly CompleWd. r L 6,�9i41f'7heApplicatiol.U� <br /> FOR OFFICE USE: F APPLICATION 11199 <br /> (For Non-Transferable, Revocable, Suspen <br /> d " J0 <br /> PU <br /> w. ENVIRONMENTAL HEALTH PERMIT LO <br /> (COMPLETE IN TRIPLICATE) D45CA WELL f <br /> WATER QUALITY SAN }G�QuiN TR1Gl <br /> t��pLTN <br /> Application is hereby made to the San Joaquin Local Health District forapermittoconstruct and/or insta11t15L'Gv'ork,hereindescribed.This application is <br /> made in compliance with San Joaquin County Ordlinance No. 1862 and th ru es and regulations of the San Joaquiq Local Health H.e,,ta.lth District. <br /> / t <br /> Exact Site Address .,[',c) City/Town — ��QC/ae as <br /> Owner's Name '! �1"a Phone <br /> Address City _54 +" <br /> Contractor's Name 'I License# s Business Phone 7 <br /> Contractor's Address l Emergency Phone t.. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 11 1 <br /> DISTANCE TO NEAREST:,L" Septic Tank `7 .7 _ Sewer Lines- 7 S— m Pit Privy <br /> Sewage Disposal Fie l±j z -� Cesspool/Seepage Pit Other <br /> Property Line /S/ Private Domestic Well '( Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 <br /> iI <br /> 4H <br /> DOMESTIC/PRIVATE A.DRILLED Dia. of Well Casing tp <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal S'/a <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout &EGr <br /> ❑ DISPOSAL © OTHER Other Information <br /> ❑ GEOPHYSICAL urface Seal installed By: L10117,fa elk- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump IJ6 A- — H.P. j <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth P <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 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 orsub-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." <br /> I ill c r a Gr t ins Ion prior to grouting and a final inspe io j <br /> r <br /> {' , . ., <br /> Signed X Title: <br /> s (Draw Plot Plan on Reverse ' e) <br /> OR EPARTMEJ4T USE ONLY <br /> PHASE I / z2 --,z, <br /> Application Accepted By Date <br /> I I <br /> Additional Comments: <br /> Phase out inspection Pha I Final inspection, <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedJanuary 31 ❑ Juiy I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> z AMOUNT <br /> FEE <br /> LESS 65" <br /> rt <br /> PRORATION S 7 Jr0 <br /> PLUS <br />� PENALTY <br /> OTHER <br /> r <br /> I <br /> I OTHER' _ <br /> W <br /> Rece+ved by Date I - -Receipt No. Permit No. Issuance Dote Mailed Delivered <br />�- APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITISERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />