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Applicailons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OS_FICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) I'E1MP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is made in compliance wit.0 5 n Joaquin CountyQrdiqarice No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address est/ F 1 City/Town ' ,[_�_ Owner's Name Phone Address / v� City A46t:o Contractor's Name License# Business Phone Contractor's Address O l�C Emergency Phone r 1� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes !may No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL, CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�-'PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer tines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other � Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ I �ST91AL ❑ CABLE TOOL Dia. of Well Excavation 1 U"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBbic- ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ` "f ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r 13 DISPOSAL ,r ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: _pr ', PUMP INSTALLATION: �; i Contractor — + J Type of Pump H.P. I 1 PUMP REPLACEMENT: ❑ State Work Do-4--. ( Mitt PUMP REPAIR: 11 State Work Done DESTRUCTION OF WELL: Well Diameter ` "-'4 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit 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', I shall employ persons subject to workman's compensation laws of California: Iwill cal 'Grout Inspection prior to grouting and a final inspection. Signed X Title: : Date: (Draw Plot Plan on Reverse Side) j p{ FOR DEPARTMENT USE ONLY I PHASE I f Application Accepted By fi Date Y/-7/90 Additional Comments: " Phase II Grout Inspection (Phase III Final Inspection Inspection By Date Inspection By = �r Date Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ©-EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` REMIT BILL3NG REMITTANCE gi -i BASE EXPLANATION t AMOUNT DUE CHEGKEp gr L PATE, DATE REML�TTED AMOUNT FEE LESS j PRORATION _ ] PLUS i� PENALTY i OTHER r OTHER I Received by Date Receipt No. Permit No. IssianceliDite Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PA,Box 2009 STOCKTON,CA 95201