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_%_ Applications Wil B Pr weed When Submitted Properly Completed. Be Sure To Sign The Application. FCM OFFICE USE: �rf ('fd APPLICATION For Non-Transferable, Revocable, Suspendable) fl' ENVIRONMENTAL HEALTH PERMIT P=AR1P ff ED (COMPLETE IN TRIPLICATE) \i WATER QUALITY 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 made in compliance with SanJoaquinCounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. /'s Exact Site Address��1 © k?2 D A , C v!_ City/Town �' to c�, �Ttr ,� 00 Owner's Name 4 _.. Phone 4 Address __ City Contractor's Name Uwi rp,4v License# Business Phone Contractor's Address Emergency Phone ��` - Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENTG— I DISTANCE TO NEAREST: Septic Tank -Fd Sewer Lines v Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation O ©'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 3 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �W ❑ 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 Z ayf e e 111 C101— u Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done ��Ffi-- �1 .- /C 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 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, I shall employ persons subject to workman's compensation laws of California." I will call for a Gr oui In c 'on prior to grouting and a final inspectio Signed X Title: . _ Date: (Draw Plot Plan on Reverse Side) FOR DEPART NT USE ONLY PHASE Application Accepted By �'t^-^� d Date G U Additional Comments: Phase 11 Grout Inspection BA I final Inspection 0 Inspection By — Date _ __ Inspection B Date Z Fee Is Due: ❑ ANNUALLY ❑ PER UNIT TZPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BELLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT AMOUNT DUE CHECKED FEE LESS �L PRORATION PLUS _"'_.--- ------ .. PENALTY OTHER OTHER Received by— Date Receipt No. Permit No, Issuance Date Mailed Delivered - APPLtCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201