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ppncations Will Be Processed When Submitted Properly Completed. Ire To Si n The - )�' ' FOR OFFICE USE: A tiot� ` i APPLICATION S E 8 I'98U E` (For Non-Transferable, Revocable, Suspendable) . � UIWA&WELL ' r ENVIRONMENTAL HEALTH PERMITSAN JOAQN L (COMPLETE IN TRIPLICATE) ATER QUALITY HEALTH DISTRICT r Application is hereby made tothe San Joaquin Local Health District for a p made in compliance with San Jermit to construct and/or install thework herein described( s appl�ca n i�2 oaqui CoCounty Ordini rice No 1862 and the rules and regulations of the San oaqui Local Health District. Exact Site Address Owner's Name City/Town� Address PhoAPhone 07�/2_ Contractor's Name �` City I License# ` Busi Contractor's Address Emergency Phone t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes. L—' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 Na © RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION WELL ABANDONMENT ❑ OTHE13 ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ ' DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f Sewage Disposal Field Cesspool/Seepage pit R Property Line O#herPrivate Domestic Well INTENDED USE Public Domestic Well TYPE OF WELL ) t ❑ INDUSTRIAL ❑ CABLE TOOL14 1 ❑ El DOMESTIC/PRIVATE ❑ Dia. of Well Excavation DRILLED pia. of Well Casing DOMESTIC/PUBLIC El DRIVEN ❑ IRRIGATION Gauge of Casing ❑ GRAVEL PACK Depth of Grout Seal ! ❑ CATHODIC PROTECTION ❑ ROTARY DISPOSAL Type of Grout ❑ OTHER Other Information t ❑ GEOPHYSICAL Surface Seal Installed By: . PUMP INSTALLATION: Contractor .� - Type of Pump H..P. ' ' PUMP REPLACEMENT: - _State Work pone PUMP REPAIR: .❑ State Work Done ' 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. f A Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forty' hich this permit is issued, I shall not employ an i P Y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ I p y persons subject to workman's compensation laws of California." I I will call I ora t Inspection prior to grouting and a final inspect; I Signed X _ � a ——— Title: Date: Z (Draw Plot Plan on Reverse Side) PHASE 1 FORD 31ARTMENT USE ONLY # Application Accepted By 7 Additional Comments: Date Ph e I ro41 Inspection � Inspection By Date ; Phas III nal Inspection Inspection By Date Fee Is Due: ❑ ANNUALLY El PER UNIT PER SITE © EAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 h BASE EXPLANATION BILLING REMITTANCE $ REMIT yy DATE DATE REMITTED AMOUNT DUE CHECKED - f FEE AMOUNT jlf LESS f PRORATION PLUS PENALTY t OTHER if OTHER 1 1'}1 '0 so 3 Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES_ 1601 E.HA2ELTON AVE:,P.O.Box 2009 STOCKTON_CA 952n1 -