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Applications Will Be Processed When Submitted Properly L;ompleiea.wesure 1U aryn rI-V..NN...a....•• For i'kcE use: -APPLICATION r (For Non-Transferable, Revocable, Suspendable) punnP&wEt>.. o� ENVIRONMENTAL HEALTH PERMIT c (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct an 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 Jo quin�Local Health District. Exact Site Address City/Town Owner's Name Phone Address City Contractor's Name License#.Z;F Business Phone_3e F--aR Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insur eon File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATIO ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT / DISTANCE TO NEAREST: Septic Tank _� Sewer Lines AQj_�2 Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 16/ Private Domestic Well Public Domestic Well INTENDED USE Lam` E OF WELL ►� 11 INDUSTRIAL CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DQJvIESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION 11GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information I4 ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. 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 3 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, 1 shall employ persons subject to workman's compensation laws of California." I will c for a Grout Insp ii pri r to grouting and a final inspect 7 Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR EPART NT USE ONLY PHASE I �Q Application Accepted By "` Date Additional Comments: Phase II Grout Inspection P II inal Ins tion Inspection By DateJ\1Inspection By to 1 Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH El 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 LESS PRORATION PLUS VV rV, PENALTY OTHER OTHER Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2E�T0 .802_`09 �TO �ON,CA 95201