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nppncati%MID vigil O4 rrug:aauaU VggG1r 0"11119tvu rF%1Pvi1Y 4-ug"PICIVu. Law Jure I u olgn I ne Nppocanon. " FOR OFFi IEMSE:� j'� APPLICATION ( or Non-Transferable, Revocable,Suspendable),11) -� ENVIRONMENTAL HEALTH PERMIT PUMP&WALL i (COMPL TE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or:install the work herein described.This application is made in compliance with San J9 unty O inance No. 1862 and th uI s and regulations of the San J a�uin Local ealth istrict: Exact Site Address ./ -e City/Town 4&Wf Oe Owner's N. (�, I Phone Address 4City Contractor's Name License# Business Phon Contractors Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ tDESTRUCTION13 WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLATION Eg'PUMP REPAIR REPLACEMENT[] DISTANCE TO NEAREST: Septic Tank v Sewer Lines APV 4— Pit Privy 1 Sewage Disposal Field Cesspool/Seepage Pit fsd ]` Other i Property Line Private Domestic Well Public Domestic Well I INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ C LE TOOL Dia. of Well Excavation 11.B IMESTIC/PRIVATE ILLED Dia. of Well Casing ! ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 ❑ IRRIGATION PGF3AVEL PACK Depth of Grout Seal _ ❑ CATHODIC PROTECTION RY Type of Grout ❑ DISPOSAL OTHER Other Information ❑ GEOPHYSICAL Surf e Seal tag d By: j PUMP INSTALLATION: Contractor i Type of Pump t P. PUMP-REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Dane DESTRUCTION OF WELL: Well Diameter Approximate Depth- Describe Material and Procedure I hereby certify that I haveprepared 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, 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I all for o nspection prior to grouting and a final inspection. p Signed X Title: Date: (Draw Plot Plan on Revere Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By ` Date�� Additional Comments: i Ph s II Grout Inspection Ph se III Final Inspection iInspection By Date Inspection By _Date �` 7 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 DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE 45 107 LESS PRORATION PLUS PENALTY OTHER OTHER 3� 1 V I. Received by Date Receipt No. Permit No. I*uancfe Date Mailed Delivered APPLICANT—RETURN ALL COPIES'TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,'P.O.Box 2009 STOCKTON,CA 95201