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_ Applications Will Be Processed When Submitted ProperlyCompleted Ise sure Ioalgn IneAPPAL LIVII. FOR oFF dc, USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) pUMQ&WELL ENVIRONMENTAL HEALTH PERMIT _ �J WATER QUALITY (COMPLETE IN TRIPLICATE) t 1 Application is hereby made to the San Joaquin Local Health District for a permit toconstructand/orinstalltheworkhereindescribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address,37 City/Town t361O Z Owner's Name Phone Address`, City Contractor's Name License#333V77I Business Phone l" Contractor's Address .0 -: Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL 1:3 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f 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 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal+^t k ❑ CATHODIC PROTECTION ❑ ROTARY ` 1,; Type•_Zif Grout ,.kms � �— - •� � ❑'OTFIER -*.- x-�- _ ' -Other Information r I ❑ DISPOSAL t `w Surface Seal Installed By: 13 GEOPHYSICAL r � , g PUMP-INSTALLATION: Contractor . Type of Pump H.P. 11 State Work Done PUMP REPLACEMENT: � PUMP REPAIR: ❑ State Work Done I ( Approximate Depth !! DESTRUCTION OF WELL: Well Diameter Describe Material and Procedure 1 , 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 of the work for which this permit is issued, lishall not employ any person in such manner as to become subject to workman's compensatioan 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." j r I will for a Grout Inspection prior to grouting and a final inspection. f Title: -.�,, e. Datef S— 7 Signed f (Draw Plot Plan on Reverse Side) E • FOR DEPARTMENT USE ONLY PHASE I Cf i Application Accepted By Date Additional Comments: Phase 11 Grout Inspectionl<.., Phase 111 Final Inspecti n a Inspection By Date "' Inspection By ate O r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By J ry 31 ❑ July 1 &%ceiveRdEByl July 31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE %I-i S LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No, Permit No. �r Is uance ate IMailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 ""