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Applications Will Be Processed When Submitted Properly Comdr 1 2�9ur o iggl n ap ton. FOR OFFICE USE: APPLICATION ;; ��,,�� I (For Nan-Transferable, Revocable, nda lei U ELL s. ENVIRONMENTAL HEALTH PERK R 26� �� WATER QUALITYI (COMPLETE IN TRIPLICATE) SM JCAWN*LUOCA�. Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct a I r t1 e niscribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. Exact Site Address City/Town Owner's Names Phone Address 5 City Contractor's Name License#/�-Z d Business Phone Contractor's Address /°-a-034 /V 7 -- G/ 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 [R'---PUMP REPAIR 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 ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I I 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: PUMP INSTALLATION: Contractor TyT of Pump H.P. PUMP REPLACEMENT: L� state Work Done �" n'`"' A. PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter KtEj Approximate Depth Describe Material and Procedure I hereby certify that l 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. Home owner 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, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X =� h2 C1Ld.s -4, � P (�gym.,, Title: . ✓ Date: ��- (Draw Plat Plan on Reverse Side FOR DEPARTMENT USE ONLY PHASE Application Accepted By__L 4 Date Additional Comments: Phase II Grout Inspection as III Final Inspection Inspection By Date Inspection By- Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE ITTED AMOUNT FEE s s - LESS PRORATION PLUS PENALTY OTHER Of OTHER � G3R Received by Date Receipt No. Permit No. ISsuan a Date Maaed Delivered APPLICANT—RETURN ALL COPIES TO'' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .