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Applications Will Be Processed When Submitted Properly Complet tl? erc'To Sign The AIiciar�. FOR OFFICE USE: APPLICATION nT Q _ (For Non-Transferable, Revocable,SuspendableV L t 20 V&P&WELL ENVIRONMENTAL HEALTH PERPA� i �, . �, ( i ' , l.,0 A - f (COMPLETE IN TRIPLICATE) WATER QUALITY d i , [ ! ' 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 J qui ITty O mance No. 18 nd the rules and regulations of the San Joaquin Local Health District. Exact Site Address z� . a City/Townn Owner's Name Phone Address ' City h� Vis► nve a Contractor's Name License# Business Phone" Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L__� No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�I 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 TENDED USE TYPE OF WELL ❑ IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing- ❑ 1 IGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ ATHODIC PROTECTION ❑ ROTARY Type of Grout ISPOSAL ❑ OTHER Other Information GEOPHYSICAL ,{ S rface Seal Installed By: PUMP INSTALLATION: Contractor 4 C Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Don �- DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure t 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, I shall employ persons subject to workman's compensation laws of California." I will for a GrInspection prior to grouting and a final inspection.Signed X ��Til `�?� C/�+~��^---- Title: •9 Dater�lL1L (Draw Piot Plan on Reverse Side) FOR DEPARTMENT USE ONLY t PHASE I GAL* � Application Accepted ByAQ �l��.OL„ Date Additional Comments: Phase 11 Grout Inspection Ph se 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 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE s LESS PRORATION PLUS PENALTY OTHER OTHER (a 0 3 Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201