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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � 6-7ti- FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PIMP&WELt 8_ Z47 w= pji h.G /s-r ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY '+. Gam• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is t made in compliance w San J aquin C unty I nce No f82 and the rule and regul 'o s of the San Jo uin Lo al Health District. � '=tAF, Exact Site Address OLL $/ if AL40 Town / Owner's Name n3 / Z1Y Phone b Address O City- y �e Contractor's Name License#� 11g Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Ins ranee on File With SJLHD? Yes X No °4 TYPE OF WORK (CHECK): NEW WELL;r DEEPEN ❑ RECONDITION❑ DESTRUCTION[] WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ j DISTANCE TO NEAREST: Septic Tank � Sewer Lines Pit Priv Sewage Disposal Field f Cesspool/Sgepage Pit OtherD12/Yt [Y.P�4�ni S13 r Property Line/0''-Private Domestic Well s�� Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation_ 6 - Ir ❑ DOMESTIC/PRIVATE )9DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C�lvr/tsir ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 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 forwhich this permit is issued, I shall employ pe ons subject to workman's compensation laws of California." I II for a rou spec' rlor to grousing and a final inspection. -� t Signed Title: Date: (Draw Plot Plan on Rever Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By � Date _.._.0 Additional Comments: 11 ut speciion Phase III Fin I Inspection Inspection By Date ,r 9 Inspection By Date Cv Fee Is Due: ❑ A NUAL ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 11&4 - Received by Date Receipt No, Permit No. Is ante pyati Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2.ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201