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L nppicaiuns vin oe r-ruceoseu mien oumnureu rrupeny a,mnpuemu. oe aide 1 u ayn r ne App"Lauum FOP OFFICE USE: APPLICATION -- or Non-Transferable, Revocable, Suspendable) PU,`AP &AVELL : _ ENVIRONMENTAL HEALTH PERMIT 'C!APLETE IN TRIPLICATE) WATER QUALITY r , pchcation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein Fheereim_desCribed:described.-This application is :nage in compliance with Sarn�1 Joaquin Co,u'nt Ordinance No1. 1862 and the rules and regulations of the San Joaquin Local Health District. <act Site Address I /i' R(7 City/Town r+ �EAG )wner's Name Iz� •��'� f Phone ('r - ddress r Jr C, ti �`� /t` City � itu �� ontractor's Name , + t' License N• G' Bues^i Ph �5�-' onlractor's Address Emergency Phone -JA s 't'-" ,_ertificale of Workman's Compensation Insurance on File With SJLHD? Yes�/o No YPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ 4MELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ i PLACEMENTh � tt STANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V' Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well Lj INTENDED USE TYPE OF WELL I INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal !I CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other information 1 GEOPHYSICAL Surface Seal Installed By: .ii,JMP INSTALLATION: Contractor ,�o Type of Pump H.P. r -UMP REPLACEMENT: 9 Slate Work Done UMP REPAIR: ❑ State Work Done .. A DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 11W 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. 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." t. Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which t Is permit is issued, I shall employ persons subject to workman's compensation laws of California." wil II fo�"roul iecti n prior to grouting and a final Inspect'Signed X Title: _7� �"� ) Date: (Draw Plot Plan on Reverse Side) �(��L FOR DEPARTMENT USE ONLY TApplPHASatlion Accepted B ' '- C51 Date Additional Comments: T Phase II Grout Inspection Phase III Final Inspection Inspection By M!n._ Date Inspection By-1 �-� { - Date T Fee Is Due: ❑ ANNUALLY r��❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January ❑ Jusy 1 8 Recervee By July 71 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DOTE— DATE REMITTED / AMOUNT ��--- -- ---111 � 1'— T EEE LE55 PRORATION PLUS PENALTY —� TOTHER