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Applications WIII Be Processed When Submitted Properly Completed.Bd Sure To Sign The Application. i OFFICE USE: APPLICATION (For Non-Transferable,Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT ALETE IN TRIPLICATE) WATER QUALITY ahon Is hereby made to the San Joaquin Local Health District fora permit to construct and'or Int.lall the work herein described This application Is n compliance with S JIn q Cc city Qtdina%e No. 1 62 and the rules and regulations of the U Local Hualth Distr,cl Site Address_ - , ^_D- _- . _ Clty/Towic G.l0/1f j G1 •'s Name ' �1.i _4;/Z"Oe-7-jo Q'll Phone -- ss ---_ . .- _ p- :-S-�: /� City actor's Nam��Qr, 2! Li nse#34,0 7V Businoss Phone -- - 71 actor's Address 2�_ �f�0 fxw Ai+- rnergency Pnnne 1 7•-4 3 -� tilicate of Workman's Com, itlon Insurance on File With SJLHD') Yes No G ` OF WORK (CHECK): NEW WELL W' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR AGEMENT❑ kNCE TO NEAREST: Septic Tank I70 Sewer I-ines Pit Privy Sewage Disposal Field /7-0 r Cesspool/Seepage Pit �/�cc Other Property Line Private Domestic Well — Public Domestic Well 4TENDED USE TYPE OF WELL / y� DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i )MESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing )MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing RIGATION ❑0�G�RAVEL PACK Depth of Grout Seal ,THODIC PROTECTION riU l ARY Type of Grout 6010' &&-'._--7�1� SPOSAL ❑ OTHER Other Information EOPHYSICAL Surface Seal Installed INSTALLATION: Contractor Type of Pump . ---------- M.P.-- REPLACEMENT: ❑ State Work Done S_N REPAIR: ❑ State Work Done .----------------_._--- _----- -- _ -_ -- i` 'RUCTION OF WELL: Well Diameter_. ___ .____.__._.__- _.. Approximate Depth Descrihe 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. 1 Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f is Issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 emp ersons subject to workman's compensation laws of California" I call for a Gr c n prier to grouting and a final Inspection. • Title: _�L��- .- ._ jam` Date: - --(-- �- d(-- (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY ` PHASE I Application Accepted By- ` -- - -- - -- - -O 4—.1-- - Date Additional Comments: - _ _-_ _.. ._ _ ____- ` Phase II Grout Inspection ase III Final IrIppection Inspection By A4-- _ Date __ 23--�1- - __ Inspection By ___ _ -11.m.,nNrOete __1--11-_�y- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 b Received By July 31 __-.---. - - ----- ---- REMIT BILLING I REMITTANCE $I BASE � EXPLANATION I AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT ss'' -- -- ---as - - FEE I "1 --------- x`� LESS �j - ---5� PRORATION - idd �c,f, __3N7.-F-�_ _ Pi.US ] P1,NAL TY _i/_I 1,lr /i Jv I �6• -r'e rLli ., ; OTHER OTHER i