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Applications Will Be Processed When Submitted Properly Complet U e�r T4fgl Tl�A&ulFOR OFFIPE_USE: APPLICATION tI(For Non-Transferable, Revocable, Sus ble)rC '9MP LL ENVIRONMENTAL HEALTH PERMIT FEB (COMPLETE IN TRIPLICATE) WATER QUALITY SAN; fC AQ'J!N LOCAL. Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or 1ri&Ik 11WorM%reeRr 1QTcribed.This application is made in compliance with San Joaquin'Cgunty Ordinance No. 1862 and the r lend regulations of the San oaquil ca! Health District. Exact Site Address �� fLA aC f City/Town 'a— Owner's NamePhone Address 7 . ._ City Contractor's Name G+v [�/- --,License#oL /0 Business Phonef o��U Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ „ DEEPEN ❑ RECONDITION[Y- -DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE tTYPE 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 ❑ CATHODIC PROTECTION ❑ ROTARY T I ype of Grout � ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL a. Surface Seal Installed By:.. PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 10 State Work Done -fes f1 1 1{1 DESTRUCTION OF WELL: Well Diameter Approximate Depth i 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. i I 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-c'ontractin'g 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." I will for Gra 1 s tion prior to grouting and a final in727 �►}` Signed X Title: Date:.2.2—IT/ (Draw Plot Plan on Reverse Side) © FOR DEPARTMENT USE ONLY PHASEIQ Application Accepted By--- Date C9 Additional Comments: Phase II Grout Inspection �Jan.-,, II ;I Inspection By Date _ Inspe A Fee IS Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE 11EACH EJJ 1 a Received By 31 ❑ July 1�61.ceived By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED ;. DATE DATE REM�IT[TED AMOUNT IFI FEE �' [ 5 LESS PRORATION - PLUS PENALTY {, r OTHER , OTHER L i Received-by Date Receipt No. - Permit No. - -..Issuance Date ;Mailed Delivered 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CAFk�201