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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE u-1;E: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT SCANNED (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 Co ty rdinarice No. 1862 and t e les an rof the San Joaquin Local Health District. yy ie e Ions Exact Site Addressdwr Xr, .SUxr'4 4 o /eo City/Town 77;?777,JCQ Owner's Name h Phone Address Q lc.� Jtsra^tL2 r�- , City— Contractor's ity Contractor's Name -rq,11 'ElIe�t . `Y / License# / Business Phone Contractor's Address s� Emergency Phone Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes y No 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 10 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed B PUMP INSTALLATION: Contractor 4 Type of Pump H.P. PUMP REPLACEMENT: C3 State Work Done PUMP REPAIR: + State Work Done - 1� ok DESTRUCTION OF WELL: Well Diameter Al5proximate 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 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 employ persons subject to workman's compensation laws of California." I III call for a Grout Insp for �gting an a final inspection. Signed Title: R 'Ill Date: r{ P (Draw PI Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspectional Inspection -G� Inspection By Date Inspection By,A= s I FinDate O 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 REMITTED AMOUNT FEE VA- LESS PRORATION PLUS PENALTY OTHER OTHER nn 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.O.Box 2009 STOCKTON,CA 95