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_ Applications Will Be Processed Whelp Submitted Properly Completed. Be Sure To Sign The Applicatiol). w:y� 4 r sic i ,jllfra%i' ADPL AGAT'iON (Fnr Noon Transferable• Revocable, Stispendabte) ENVIRONMENTAL HEALTH PERMIT" � .OMPLETE IN TRIPLICATES WATER QUALITY pplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Phis application is 'lade in compliance wig+/Spin•I-aquin County,�OOrdinance.No 1862 and the rules and regulations of the Sar, .Joaquin Local Health District. ^ ? xact Site Addressf „ e •'TGG' City/Townes -wner'sName �� J`i/✓k1��-t Phone .35�� { ,address X31�2 y hi .S r_�T `!s_� —___ City T1 g �>e __ 1 ontractor's Name &stc,3' .._ icense %':;[, Business Phone_ , ^ "ontractor's Address / ` Emergency Phone Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ^• YPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ .JELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ IEPLACEMENT;w —ISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other---- Property ther __Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL �I INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation ______. _. DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _... I DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing —1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I CATHODIC PROTECTION ❑ ROTARY Type of Grout _ _ - -- - 3 DISPOSAL 13 OTHER Other Information ..,� GEOPHYSICAL Surface Seal Installed By: _—.._. 'UMP INSTALLATION: Contractor -- - — Type of Pump .. _ H.P.— D h SUMP REPLACEMENT: State Work Done. ,,_,, �f �+rwd 'o,5% 14e �---- `\�\ �'UMP 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. Home owner 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 L1111for a Grout Inspectionprior to grouting and a final inspection. Signed X Title: _ er -- Date: -- �h1 (Dr�yy� f Plot Plana Reverse Side) l ¢ / B. �f -. FOR EPARTMENT USE ONLY ice" _z Del- 4Z/ PHASE I Application Accepted By �— Date .� Additional Comments: - —� Phase 11 Grout Inspectiona I11 Fi 1,n tion : + Inspection By __. Date._.—. Inspection B),J;• Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar l ❑ July 1 &Received By July 31 --' REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT ` SCE LESS ` PRORATION -.•- -- PLUS PENALTY .—_._..... . — OTHER OTHER C '17C'7 l I _97