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Applications Will-Be Processed When Submitted-Properly Completed. Be Sure To Sign The Application. t F(YR OFFICE USE: APPLICATION i s9t Ie�c� (For Non-Transferable, Revocable, Suspendable) �¢� •- PU P&WELL ENVIRONMENTAL HEALTH PERMIT (/ (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is made in compliance with San Joaquin County Or inane No. 1862 and the rules and regulations of the San Joaquin I,acal alth District. Exact Site Address ✓ Ct 76 City/Town GIC` ,I�t{ Owner's Name ig D�. A I41J04 d', Phone Address / �m I'll« & i aAl Al City Contractor's Name •✓ a x License 41J:� 7 Business Phone V6 ,-J&7 Contractor's Address u� a9 Emergency Phone ' Is Certificate of Workman's Compensation Insurance o File With SJLHD? Yes X — No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ od WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer,Lines Pit Privy Sewage Disposal Field '--Ce`sspool/Seepage Pit Other g Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELLrt ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation JA 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 1 ❑ DISPOSAL ❑ OTHER Other Information ti ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 4 ,Ve asrf ' Type of Pump C�� _..si1b H.P_ PUMP REPLACEMENT: JN State Work Done 'POW 20,nwa'l x' " � rg eft.ca 0C PUMP REPAIR. ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth i f 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 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 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 permit is issued, 1 shall employ persons subject to workman's compensation laws of California." r I w'll call fora Grout Ins Yectio� il) u`ng a d a final inspection. Signed ui®W I'll, Title: ; ' _- Date: 'Y (Draw P t Plan on Reverse Side) f FOR.DEPARTMENT USE ONLY - PHASEI Application Accepted By _ Date Additional Comments: Phase 11 Grout Inspection 41 P s I Final Inspection ;�7 O ' Inspection By Date -_ - inspection By Date _ rdf®'o I , Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ed By January 31 .❑ July 1 &Received By July 31 r - REMIT BILLING REMITTANCE $ BASE EXPLANATION ' DATE DATE REMITTED AMOUNT DUE CHECKED (� AMOUNT FEE LESS PRORATION PLUS I° PENALTY OTHER OTHER ar c 14( 61 ... Received by Date Receipt No. Permit No. ssuan Dalb Mailed Delivered APPLICANT-RETURN AL•L^COPIES TD:"-'ENVIRONMENTAL HEALTH PERMIT/SERVICES.,_,u� 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201