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,, Applicaiions.- Will Be Proces ed When Submitted Properly Completed. Be Su n Ica to . e pp FOR OFFICE-USE: APPLICATIONSE: � "`� MAR ' F� (For Non-Transferable, Revocable,Suspendable) 111980 &WELL ENVIRONMENTAL HEALTH PERMIT SASj4 r,Q1,Jf f LOCAL , (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH Q1STRiOT Application is hereby made to the San Joaquin Local Health District fora perm itto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 18 and the rules and regulations of the San Joaquin Local Health District. 3 V ,, City/Town ��4L,- V Exact Site Address /�� Owner's Na �� -� CC�� '^� Phone r Address 2 �- City Contractor's Name AC 7_ License# Business Phone 2- Contractor's Address �� Emergency Phone Is Certificate of Workman's Compensation Insurance"on File With SJLHD? Yes�"� No — TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 11 WELL ABANDONMENT C] OTHER 11PUMP 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 ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION 11 GRAVELPACK Depth of Grout Seal 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ 1 ❑ DISPOSAL ❑ OTHER Other Information I ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor '44 9 ! Type of Pump , H.P. Z !� PUMP REPLACEMENT: 10 State Work Done PUMP REPAIR: IJ State Work Done DESTRUCTION OF WELL: Well Diameter /Appro 'ma Depth Describe Material and Procedure I hereby certify that I have prepared this aprlication 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 r 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 performa e of the work for which thi permit is issued, 1 shall employ persons subject to workman's compensation laws of California." ��;;„; e _ j� I will III r a GG I Inspection prior to grouting and a final inspection. Signed X Title: "� Date: (Draw Plot Plan on Reverse Side) FOF3 DEPA13TMENT LISE ONLY PHASE I ,O O Application Accepted By - Date j Additional Comments: Phase II Grout Inspection Phase Ili Final Inspection Inspection By Date Inspection By Date Z Fee i5 Due- ❑ ANNUALLY PER UNIT tR PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREWTuly.31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I DATE DATE REMITTED AMOUNT FEE �'s LESS PRORATION F PLUS 1 PENALTY 'y OTHER F OTHER m � Received by. � Date Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAYE.,P.O.aox 2009 STOCKTON;CA