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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k" FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ' ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY ' Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instal I the work herein described,This application is I 1 made in compliance-with-San-Joaquin-Count _Ordinance No. 1862 and the rules and regulations of the Joaquin Health District. Exact Site Address S- $.� — ®�C City/Town C Cf}1 6^�. ems' fi Owner's Name fE S Phone Address 2 S Citytom, Contractor's + 1}L�fcense�fa� P1 Business Phone_ Y2–. p + Contractor's Address C, –+ ., mergency Phone Gam[ 7— Ct,3 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <— No 0` TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V I`k WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ d R,EPLACEMENTO;#� DISTANCE TO NEAREST: Septic Tank �� Sewer Lines �d fes. Pit Privy Sewage Disposal Field�Jf.--7'-_ Cesspool/Seepage Pit /fra_k� Other f Property Line Private Domestic Well �— Public Domestic Well ---��, ! INTENDED USE TYPE OF WELL ❑��INDU�STRIAL ❑ CABLE TOOL Dia. of Well Excavation I�`UUMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �.: ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal d ❑ CATHODIC PROTECTION 2PITOTARY Type of Grout Q A, a - ❑ DISPOSAL ❑ OTHER Other Information � r1-8 'TUQ i ❑ GEOPHYSICAL urface Seal Installed By: r 62 S . �M C 1 PUMP INSTALLATION: Contractor — /[ 4 (r i r /ArC • . _ Type of Pump HP � PUMP REPLACEMENT: ❑ State Work Dane } PUMP REPAIR: ❑ State Work Done `J DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County R ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall emp ersons subject to workman's compensation laws of California." call for a Grou c on for to grouting and a final inspection. { Signed X r Title:f:Z?ESL I o om Cr. Date: Z� i (Draw•Plot Plan on Reverse Side) I FOR DEPARTMENT USE ONLY PFt ) Application Accepted By """"-- Date r Additional Comments: I Grout Inspection i Final Inspections Inspection B Date i\// I Inspection By Date Fee IS dile: ❑ ANNUALLY,. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Reeived By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT �1 a FEE �� x LESS ' PRORATION PLUS PENALTY OTHER OTHER ` Received by Date -Receipt No, .Permit No. Issuance Date .Mailed Delivered APPLICANT—RETl1R YLLL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1501 E.HAZELTON AVE.,P.D.Boa 2009 STOCKTON,CA 9520 r r t a R.