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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION , > <br /> (For Non-Transferable, Revocable, Suspendable) U / <br /> PU P&WEEf_ r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. \ ' <br /> Exact Site Address ,s�_,4. C42!!f� City/Town "C"14A04) <br /> Owner's Name _ ��^ �'I Phone <br /> Address �� �I� � City <br /> Contractor's Name License Business Phone a-3 y•� <br /> Contractor's Address A/ /�� /� Emergency Phone <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 INSTALLATIONA PUMP REPAIR❑ ` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ` <br /> "Sewage Disposal-Field" Cesspool/Seepage Pit "' dth& <br /> Property Line Private Domestic Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL 11 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/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 yr Type of Grout r , <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal_Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ( 7, , <br /> PUMP REPLACEMENT: ❑ State Work Done t" <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Le- Describe Material and Procedure f- } <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 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." <br /> I will tali for a_Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: C Date: <br /> (Draw Plot Plan on Reverse Side <br /> FOR DEPARTMENT USE ONLY <br /> PHASE - <br /> Application Accepted By e,,," Date3 <br /> 4 It <br /> Additional Comments: ' <br /> Phase II Grout Inspection Phas III Final inspection <br /> Inspection By bate :Inspection By�� Date 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT 1 <br /> NY <br /> BASE EXPLANATIOAMOUNT DUE CHECKED .'I <br /> i� i:." -- t r 3 DATE DATE REMITTED - AMOUNT <br /> �•i:.FEE -d t � - <br /> LESS <br /> PRORATION t i <br /> PLUS , <br /> 'P,ENALTY q, n <br /> OTHER <br /> Received by Date Receipt No. Permit No. 194jancelOale Mailed Delivered <br /> APPLICANT.:-AETURN ALL COPIES TO:—ENVIRONMENTAL HEALTH PERMIT/SERVICESa --'1601 E.HAZELTON AVE.,P:O._6_o'K-2009 --STOCKTON,CA 95201 _ <br />