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Applications Will Be Processed When Submitted Properly Compl �. Au Tl i 'rfe li tl l } FOR OFFICE USE: APPLICATION - (For Non=Transferable, Revocable,Suable 15 P �L IPPl�`" ENVIRONMENTAL HEALTH-PERMIT OCALA(COMPLETE IN TRIPLICATE) + WATER QUALITY SAN j0,'WU1N LOCAL- Application pplication is hereby made to the San Joaquin Local Health District fora permit to construct and/ggEAtjll�h 1� 0� scribed.This application is made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 31 JI—? 77 Ler, # ,. � /Z_P City/Town 1<96 .1 Owner's` Name 0!9'' /i`+ �e,a1r.J`}' # . , ,,, Phone Address - 9 i "`" ?»'a �.�c ),p 1 City �� Contractor's Name �9�e� �wYr'.:�_A1 ' '"-License# 16.E J73 Business Phone Contractor's Address P"eaz ' f Emergency Phones Q} Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ,/ No ) TYPE OF WORK (CHECK): NEW WELL❑F " DEEPEN ❑ RECONDITION❑ DESTRUCTION❑WELL "CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ I - i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well F INTENDED USE TYPE OF WELL ❑ }{�DUSTRIAL ❑":CABLE�TOOL . Dia. of Nell Excavation DOMESTIC/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: PUMP INSTALLATION: Contractor Type of Pump H.P. ; PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: EState Work Done - DESTRUCTION OF WELL: Well Diameter Approximate Depth . �" It- Describe Material and Procedure I hereby certify that I liave'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. 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 forwhich 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.y� Signed X +L� Title: Dale: { (Draw Plot Plan on Reverse Side) ' FOR DEPARTMENT USE ONLY PHASE Application Accepted By n"1 Date Additional Comments: Phase II Grout Inspeclion ase III Final Inspec n Inspection By Date Inspection By Tom' Date 3 Z Fee Is Due: ❑ ANNUALLY" ❑ PER UNIT ❑ PER SITE" ❑ EACH, ❑ January 1 &Received-By January 31 ❑ Jury 1 &Received By July 31 REMIT BILLING ?.. REMITTANCE- $ FBASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED " AMOUNT FEE x_. t, �.t• ,. i 'sO L.1{ , LESS PRORATION PLUS _ r PENALTY OTHER } OTHER - i f Received by- •• -Date – - Receipt No."-. Permit No.. ._ ,Iss ante Date �. Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009BTOCKTON,CA 95201 1