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Applications Will Be Processed When Submitted Properly Completed. Be-Sure#TasSI T eirApp' ti <br /> I` FL�:oFFICE USE: APPLICATiQN V <br /> (For Nan Transferable, Reroc�a�hle,Susperidable) f <br /> Puk WELL / J <br /> ENVIRONMENTAL HEALTH PERMIT JU-tri 2 1981 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/orSkk thiels/ofk 1`WP4irLc@Cb1.�15�ed.This application is <br /> made in compliance with JJ,oaXinrcounty Ordinance No. 1862 and the rules and regulations 04.Eep, aFL ut �L ¢ Fleal District. <br /> Exact Site Address f�G City/Town -J tf� �- <br /> Owner's Name > Phone r <br /> Address L�1 ✓� '� City <br /> Contractor's Name icense # Busi ess Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensatio 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 M-/ <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �41DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> T.yyp -f Pump FI,P, <br /> PUMP REPLACEMENT: L State Work Done <br /> PUMP REPAIR: ❑ State Work Done J <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 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 orsub-contracting sig at re <br /> certifies the fallowing:"I certify that in the performance of the work for which this <br /> per issued, I shall emplo persons ubject to w rkman's compensation laws of California," t, <br /> will c 1 for a Grou In e i n prior grouting d a final inspection. <br /> Signed X <br /> Title: _ Date: J <br /> ( raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I F(Y1 all— <br /> Application Accepted B 1' 1 4 Date <br /> Additional Comments: <br /> has 11 Grout Inspection se III Final Inspection <br /> Inspection By Date Inspection By T `4 DateI It <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ Ju€y 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> Pit AMOUNT <br /> FEE Ts_17 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />