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Applications Will Be Processed When Submitted Properly Completed.Be It—ro`iign The Application. FOR OFFICE USE: APPLICATION J-1' a � r, On f3 e (For Non-Transferable,Revocable,Suspendable) `� '�POAPX- ELL ENVIRONMENTAL HEALTH PERMIT VATJ yiOAQUIN LOCAL (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT Application is hereby madeto 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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addres 1.1 n(174 91 1@t �7r City/Town Owner's Name a &n Phone Address ity t , Contractor's Name License# usiness Phone ej�W 42 Contractor's Address 0 A Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—� No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ 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 Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ 1ND,,�,ISTRIAL 13 CABLE TOOL Dia: of Well Excavation h D/O_MESTIC/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 Surface Seal Installed By: d— CR PUMP INSTALLATION: Contractor Type of Pump H.P: >: PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: �ate 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. 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 for which this 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. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY j PHASEI Application Acceptedy Date" —zQ Additional Comment . Phase II Grout Inspection I I pection Inspection By Date Inspection- Date 7 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan ry 1&Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 4 L LESS PRORATION PLUS PENALTY OTHER OTHER IIs Received by Date Receipt No. Permit No. irtuance qat6 Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.