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Applications Will Be Processed When SubmiHed Properly Completed. Be Sure To Sign The Application, FOR-OFFICE"USE: APPLICATION ❑ DRILLED Dia. of Well Casing (For Non -Transferable, Revocable, Suspendable) Gauge of Casing _>. PUMP & WELL ❑ ROTARY -------------- - ENVIRONMENTAL HEALTH'PERMIT Other Information MPLETE IN TRIPLICATE) WATER QUALITY se III Final pettion PICis hereby made to the San Joaquin calHealthDistrict fora permit toconstruct and/or install the work herein described. This application is made in compliance with San Co o� rdinanc o 2 and the rul s a regulations of the San Joa na.ocal Health District. ❑ PER UNIT ❑ PER �J'o°'aquin Exact Site Address a _ _ City/Town Owner's Name _ Phone Address .� _ ._. ._.__ _._____ city_ ,�,etFw~w�:�►••—� f Contractor's Name__ License # Business Phone .I BILLING Contractor's Address r _' ir Emergency Phone T7 I Q VAW Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ _.__. t TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ S WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIPA DATE REPLACEMENT ❑ AMOUNT DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line _ Private Domestic Well Public Domestic Well INTENDED USE ❑ INDUSTRIAL DOMESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL ❑ GEOPHYSICAL PUMP INSTALLATION: PUMP REPLACEMENT: '%4P REPAIR: iTRUCTION OF WELL: TYPE OF WELL ❑ CABLE TOOL Dia. of Well Excavation ❑ DRILLED Dia. of Well Casing ❑ DRIVEN Gauge of Casing ❑ GRAVEL PACK Depth of Grout Seal ❑ ROTARY Type of Grout ❑ OTHER Other Information Surface Seal Installed By: Contractor Type of Pump t❑ State Work pone._ t++i State Work Done Well Diameter Describe Material and Procedure H.P. _ Approximate Depth 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 1 will call for a Grout spectlon prior to grouting and a final inspe ion. Signed'Xl _ Title .._._ -- --- _ __... Date: 4 (Draw Plot Plan on Reverse Side) ) FOR DEPARTMENT USE ONLY PHASE I Date —� d Application Accepted By �A� ---- Additional Comments: - -___ Phase II Grout Inspection se III Final pettion Inspection By Date inspection B ate Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ FACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER i OTHER so Rece,.ved by Date. Receipt No. Permit No. Iss nce Dal Mailed Delivered (_/,ter\} e ea, ,reur—aeT, mu ni , rnemc Tn- euumnuuCutni ueel Tu oFaurrl ravirFS 1R0f F. HAM TON AVE.. P.O. Raw 1009 STOCKTON. CA 95247C'�fl l