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Applications Will Be Processed When Submitted Properly Completed. Be S Sign The Application. OFFICE USE: APPLICATION DCT 9 1979 (For Non-Transferable, Revocable, Suspendable) g�� ENVIRONMENTAL HEALTH PERMIT SAN J4F.QU11`r LMXLELL (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin CoUDIV Ordinance N 1 62 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address �7 City/Town d Owner's s -, �'rPhone A Name Address City /ts� i` Contractor's Name S License#� Business Phone `7��'- Contractor's Addria ss 0Lr 4 Emergency Phone . Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f—~' No r TYPE OF WORK (CHECK): NEW WELL Z--'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ A WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank O Sewer Lines A� 0 Pit Privy / 6 j Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ' �ff CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 14-� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ! y WiRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N ❑ 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. 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 I permit is issued, I shall employ persons subject to workman's compensation laws of•California." I will call for a G out Inspection prior to grouting and a final inspection. �� ` k Signed X Title: ��- �q� Dati -m ` 1 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted B L Date Additional Comments:if. 8o N � V — - ��hV� Phase Grout ' _ Inspection Phase 111 Final Inspection Inspection By Date Inspection By Date 44 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 CIECKED AMOUNT DATE DATE REMITTED f +f FEE LESS - PRORATION PLUS PENALTY OTHER OTHER 6,2 79-4)4b a Received by Date Receipt No Permit No. Issu nce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201