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Applications Will Be Processed When Submitted Property Completed.Be Sure To SignTheApplication. FOR OFFICE USE APPLICATION 1."dr Non-Transferable,Revocable,Suspendable)�s� P � ENVIRONMENTAL HEALTH PERMIT FF �� ,V" (COMPLETE 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 SPn Joa ul pc/ount Ordina ce No. 186�7✓,Jand the rules and regulations of the San Joaquin local Health District. Exact Site Address],,,, 4V O � 'f 4 / City/Town S'7/_-�G�T`rH Owner's Name �' �I 4 it Phone AddressenGb (J + Contractor's Name 1 Q, Licsee - - B sines.Phone Q�/r71 Contractor's Address .4=lmk ftEmergency Phon 1112 6— Is Certificate of Workman's Compensation Insure on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL( EEPEN ❑ RECONDITION❑-- 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 NOther Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL . ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavationill — DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a Q - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - ❑ IRRIGATION ❑, GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION o/ROTARY Type of Grout Ta"'t—e°is ❑ DISPOSAL ❑ OTHER Other Information ��1 13 GEOPHYSICAL Surface Seal Installed By: Oda= Xe e- PUMP INSTALLATION: Contractor Type of Pump H.P. r PUMP REPLACEMENT: 11 SlState Work Done ian PUMP REPAIR: rr State Work Done dW U p DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 hereby certify that I have prepared this application and thai IRS work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distrlc Home owner or licensed agent's signature certifies the following:"I certify that in the perfomppance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to work�an's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following:"I certify that in t e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." cal for a Grout Inspection a to gr ng and anal Inspection. - Signed X - Title: Date, (Draw Plot Plan on Reverse Side) - FOR DEPARTMENT USE ONLY PHASE 1 // Date Application Accepted By Additional Comments: Phase 11 Grout Inspection > -7_ hase III Finalalo_speeion Inspection By 9 B.l-S/ Date � /- "`'�� Inspection By �"' Date 16--V Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1&Received By January 31 ❑ July 1 3 Received By July 31 REMIT BASE E%PLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT _ FEE 4 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Ijauance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 201119 STOCKTON,CA 85201