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r.pMu v....v.n rrm vc.-.w•.c�acw .r.w..ww 1.....cw I.-r—y —ww.v i v w.y.. .�.c r.[,.r.wauw.. i FOR OFFICE USE: APPLfCAt1ON n '� � .� For Non-Transferabie, Revocable, Suspendable i PL)N1P&WELL � i ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance w"hSan,Joaquin County Ordin nce No. 1862 d the rules and regulations of the San oaq 'n Local Health District. Exact Site Address // City/Town �,rr Owner's Ni e a Phone �Q Address City Contractor's NameLicense# MY Business Phone Contractor's AddresE*06 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes N TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTI �, 7�,JvA 3—ii -- WELL CHLORINATION C3WELL ABANDONMENT C1 OTHER PUMP INSTALLATION PUMP R PAIR❑ 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 Q 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 ❑ GEOPHYSICAL Surfa Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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. 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-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call too a Grout Inspection prior to grouting and a final inspection. Signed X _ Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application.Accepted By P�P ' Date 6-2 Additional Comments: i Phase II Grout Inspection PhaseT al Inspection Inspection By Date Inspection By ate R fz-Lf/ fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE S a Q LESS PRORATION PLUS PENALTY OTHER OTHER . Received by Date Receipt No. Permit No. Issuance bate Mai€ed Delivered APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201