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ltpplications Will Be Processed When Submitted Properly Compl til B "the�plL4. FOR OFFICE USE: APPLICATION 1 JJUU " + (For Non-Transferable, Revocable,Su l able) jj P&WELL ENVIRONMENTAL HEALTH PERMIT �AQUIN FOCAL WATER QUALITY NtE�` ;� [} (COMPLETE IN TRIPLICATE) Q S�,`'��3tI�W T(�STRICT, Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or Ilr" or herein described.This application is made in compliance with San Joaquin County Ordi a No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 4:44f SiCe�o��- C&c- TF frvHc 4y,e � City/Town. !/—& q 70-L� Owner's Name H n u Phone 0 Address D r1 City ✓fa h U c-cf— Contractor's Name License# 5!9t R_ ,.Business Phone Contractor's Address 5mergency Phone Is Certificate of Workman's Compensation Insuranc on File With SJLHD? Yes No t TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 01 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank too Sewer Lines 4 Pit Privy Sewage Disposal Field r./« 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 It& 0S ❑ IRRIGATION RAVEL PACK Depth of Grout Seal - ❑ CATHODIC PROTECTION ROTARY Type of Grout l ❑ DISPOSAL ❑ OTHER Other Information /1, Y ❑ GEOPHYSICAL Surface Seal Installed By: �O6 PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance ofthe 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 I sp tion prior to grouting and a final inspection. Signed X Title: ©�f/�'1.t Date: a1 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By �""'�^� ate, Additional Comments: P e II Grout Inspection �+I 2��- n P ase III Final Inspection Inspection By ' Date (� Inspection `1 f! Date 6—Z Fee 1s 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 PRORATION _ PLUS PENALTY OTHER OTHER 1 �ct"3 1 �- Received by IDat4 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,OA 95201