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lIt kk 4t �ti' I Applications Will Be Processed When Submitted Properly Comp e Be Sane ifci Srgn The ppl 'a i n. FOR OFFICE USE: APPLICATION (Far Nan-Transferable, Revocable,St �Pl�ndableut� ,I MP&WELL ENVIRONMENTAL HEALTH PERMITv (COMPLETE IN TRIPLICATE) WATER,QUALITY k,41i ' CT „ Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/ol'tih �{ o erein described.This application is made in compliance 'th SS nn�Joa�+iin Co my Ordinance o. 1862f nd the rules and regulations of the San Jo u'n Lo I Health Distric . Exact Site Address ail O / 6. .Gdl� Cti7yey v/w City/Town Owner's-Norse Phone 'y Address City - Contractor's Name �iM icense# 4=71 Business Phone 9 / Contractor's Address �7� U 7.r1� R1.0�� Emergency Phone' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No j TYPE OF WORK (CHECK): NEW WELL 'DEEPEN ❑ RECONDITION _ .. 'DESTRUCTION El WELL CHLORINA ION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ .`-, j t REPLACEMENT ' DISTANC_E-TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Dorriestic Well Public Domestic Well INTENDED USE STYPE OF WELL s-` _ ElINDUSTRIAL ❑ CABLE TOOL ) Da-of'WellExcavation I ❑ DOMESTIC/PRIVATE Q DRILLED Dia. of Well Casing w ❑ DOMESTIC/PUBLIC ❑ DRIVEN i Gauge of Casing iF ❑ IRRIGATION O GRAVEL PACK Depth of Grout Seal a. ❑ CATHODIC PROTECTION - ❑ *ROTARY Type of Grout O ❑ DISPOSAL ❑ OTHER j Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION`— Contractor ` F 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. if Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permitr t is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." 4 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 I I call for a Grout Inspection prior to grouting and a final Inspection. .i: Signed X Title: , –� �� Date: (Draw Piot Plan on Reverse Side) : f FOR DEPARTMENT USE ONLY t PHASE I i Application Accepted By 2N= Date !telC ! Additional Comments: r t Phase II Grout Inspection € rRb se III Final Insp~ n E Inspection By ( Date } Inspection By ate �z • Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH Cl January 1 &Received By January 31 ❑ July 1 &Received By July 31 I BILLING REMITTANCE $ REMIT BASE EXPLANATION ?ATE DATE REMITTED AMOUNT DUE CHECKED r AMOUNT . FEE fh t4rm�• - �"_ LESS ul PRORATION I - PLUS PENALTY j r OTHER -j - -- - OTHER E 1 )10 S -Received by - Date i ' Receipt No Permit Nokissuan a Date Mailed Delivered ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201