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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Fog OFFIc-USE: APPLICATION �� --(For NiSn-Transferable, Revocable, Suspendable) 1 '0 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) l x 4-T� ...WATER QUALITY I 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 i made in compliance with San Joaquin County Ordinance No. 1862 and t e rules and regulations of the San Joaquin Local Health District. i Exact Site Address OGC4 rOrlS rz_J /fie✓ City/Town �7dC4:77 tV�.. G�Cc _ 11 �5`fi�a+- ,da�t� .Yt c��✓ . _ Owner's Name [L/— � t��z - Q� �Q �/� Phone I Address �F 0d f'O�So+s-i ,3/L/_d- �57—a C—ty— City_ 1 Contractor's Name License# Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C.] PUMP REPAIR ` REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I Sewage Disposal Field Cesspool/Seepage Pit OtherC42416nJ4. , Property Line Private Domestic Well Public Domestic Well ! s �� I INTENDED USE TYPE OF WELL ©'INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - — ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I 01DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 111RRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑, , '�D POSAL ❑ OTHER Other Information Q`GEOPHYSICAL y�� Surface Seal Installed By: PUMP INSTALLATION: Contractor d 11 Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter sr 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. 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 fora ou I coon prior to grouting and a sinal inspec ion. Signed X Title: — 3>� -' Date: _ I� (Draw Plot Plan on Reverse Side) ` FOR DEPARTMENT USE ONL PHASEI k Application Accepted B V Date i Additional Comments: Phase 11 Grout Inspection ase III-Fina1 spection Inspection By Date Inspection By -ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE { LESS PRORATION PLUS PENALTY OTHER OTHER -7Ld-q �Y6 7 Received by IFDate Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boa 2D09 STOCKTON,CA 952