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Applications Will Be Proceased When Submitted Properly Completed. Be Sure To Sign The Application. 'FORpr FACE USE: •: APPLICATION (For bion-Transferable, Revocable, Suspendable) Wl l-I. ENVIRONMENTAL HEALTH PERMIT I'lJM1'Fa (COMPLIETE IN TRIPLICATE) -Uw� � - � " �ATEII QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in'� ornpliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address_ � i�TrF1L � } 1 '.utIIGrJT'j, L,rVt'SCity/Town _ Owner'sI Name ��'`"y•� �^� Phone Address — --------._. City ---- — — lT Contractor's Name License # Business Phone 3 V- /6 Contractor's Address,]/WCx CcijTAWL 01 A UL-Q Emergency Phone Is CerWicate of Workman's Compensation Insurance on File With SJLHD? Yes✓T- No _ I TYPE O'F 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 j s I ❑ INDUSTRIAL ,❑�,�CCABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE IJd DRILLED Dia. of Well Casing 4 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `- C i 11iRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER _ r_ Other Information �_'�.y ._ ❑GEOEPHYSICAL t� A�Surf eatgl, ,,t_all d _ PUMP iNSTALLATfON: on,ra�cto� , V� ' -7 "' "^' I >: .l� Type of Pump— � _ H.P.•---_—____— PUMP REPLACEMENT: © State Work Done -` PUMP 1416AIR: ❑ State Work Done _ f DESTR kTION OF WELL: Weil Diameter Approximate Depth Describe Material and Procedure � j_i �c'[rr4 �� ?, LL....m� 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. At7VS111 t Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this rmlt is i sm)d, I Slmll not employ any poison in such rnannor ns to become sub)ocl 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 forwhich this permit iS issued, I shall employ persons subject to workman's compensation laws of California." w I call for a Grout In pectition pr r to grouting and a final Insp ctlon. r Signed X t�L� �/ TL 's �src Title: � C' C?ti� ' Date: f (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PASE I Application Accepted By _ Date d F Additional Comments: Phase N Gro 1 Inspection �� Phase III Final Inspection Inspection By Date Inspection By Date _ r Fee is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 BILLING REMITTANCE � $ � REMIT BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED _-, AMOUNT FEE LESS PRORATION r PLUS � -- ,__-_-_�.. --- ., --- ---•— _ PENALTY OTHER .,k. ;t OTHER _I ..........,. I Received 6y Date Re Permit Na. Issua�ce?DQC Mailed Dehvered II 'IIAPPLICANT—RETURN ALL COPIES TO: �ENWRONM ENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.p,Box 2005r5CA AUnj