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Applications Will Be Processed When Submitted Properly CompleWJtAure To Sign The Aplic FOP FFICE USE: APPLICATION � RyO� �1 197�J (For Non-Transferable, Revocable, Suspendable)t`� ( P&P&WELL ENVIRONMENTAL HEALTH PER��N j� p�iS � (COMPLETE IN TRIPLICATE) WATER QUALITY �> p,LT 10, Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install the work.hereindescribed.This application is 6 made in compliance with San Joaquin Count Ordi a e No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address -27-39V Ar'. WIA City/Town 4J Owner's Name a;ir-- Z�-_ Si -yQ Phone ft - Address City 4 C,4"A) Contractor's Name lVe Ss.- License#.Z7%0/G Business Phone O Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ...I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type Of Grout ❑ DISPOSAL ❑ OTHER Other Information' ❑ GEOPHYSICAL Surface Seal Installed By: V1 r PUMP INSTALLATION: Contractor t Type of Pump H.P. 1 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: Ed State Work Done -P—. DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit c 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 for which this fpermit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Ins n p ' r to grouting and a final inspection. f Signed X Title: � 1;2 Date: (Draw Plot Plan on Reverse Side) F R D PARTMENT SE LY PHASE / Application Accepted By Date / f Additional Comments: Phase II Grout Inspection Ph se 11 Final L7spectlonp Inspection By Date .. Inspection B Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 _ 'REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED "' DATE DATE REMITTED AMOUNT FEE : LESS _ I PRORATION PLUS PENALTY OTHER OTHER 71 Received by Date L, Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA' t �.