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FOR OFFICE USE: APPLICATION `(ror Non-Transferable, Revocable, Suspendable) I'lJMP&WELL ENVIRONMENTAL I�tALTH PERMIT (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 S n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 6 ell City/Town ' Owners Name C2=1r ` Phone Address City Contractor's Name `S License#,V.(Q .6 r?lk-, Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation lnsurance on File With SJLHD? Yes- �T No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑�WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I 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 TYPE 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 Type of Grout ❑ DISPOSAL .❑ OTHER Other Information {l,i ❑ GEOPHYSICAL. Surface Seal Installed By: U i PUMP INSTALLATION: Contractor Is Type of Pump H.P._ PUMP REPLACEMENT: [];State Work Done_ PUMP REPAIR: ❑.State Work Do DESTRUCTION OF WELL: t� Well Diameter Approximate Depth Descibe Mat riot and Proced re % ell I hereby certify that I have prep ed this application an 4 at the work will be done in accordance with S YJoaquin 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 performarice of the work for which this permit is issued, I shall not employ any person_irLsucr.manner_as._to._Iecome 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 for which IN permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. f �y Signed X �v'lL/t't' �.J Title: Date: (Draw Plot Plan on Reverse Side) l FOR DEPARTMENT USEIONLY PHASE I Application Accepted By _4 Date j Additional Comments: Phase,ll.Grout Inspection hasq III F' I inspection Inspectibn By Date Inspection By � Date ��- i Fee Is Due: 0 ANNUALLY El PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1&Received By,January 31 ❑ July f &Received By July 31 5 t - BILLING REMITTANCE REMIT .BASE 'EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE CD LESS / PRORATIONPWS I I PENALTY OTHER f OTHER ' i E Received by M "'"'"�"Date' "" """""Receipt Np.'-' _- "-Permit,No"-"- Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES T6: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201