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Applications W0I Be Processed When Submitted Properly`Completed. Be S 0i5lgnThe Application. �- FOR OFFICE USE: Y APPLICATION 1979 (For Non-Transferable, Revocable, Suspendable) DEU + S] p SAN J0A01111� -ELL . ., ENVIRONMENTAL HEALTH PERMIT ' W (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH pySTRtCT 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 7 made in compliance with San Joaquin County Ordinance No. 1862 and the rukl s and regulations of the Sari Joaquin Local Health District. Exact Site Address 1& ,538 S> C.CJ,,A oGe ./e 11 City/Town 4-S G 41.0 -J Owner's NameR ae�Q 12 0 S PZ e_ Via., Phone 1? 14,Z2 Address SZ _ city �F. .r4.�os•✓ Y Contractor's Name 7",a &I W-41af011 ired License# 790)b Business Phone_ ��-� d7 Contractor's Address Emergency Phone 5W Z21 t! Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ad)g� No f TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r Sewage Disposal Field Cesspool/Seepage Pit Other- Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL d ❑, 1.�DUSTRIAL 11CABLE TOOL Dia. of Well Excavation Eli DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal } ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: J PUMP INSTALLATION: Contractor + Type of Pump H.P. PUMP REPLACEMENT: ❑ Skate Work Done �� r I PUMP REPAIR: tate Work Done ,��- Lt!d� d P'''te—� DESTRUCTION OF WELL: Well Diameter Approximate Depth ' Describe Material and Procedure r-- 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." a j Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this d permit is issued, I shall employ persons subject to workman's compensation laws of California." ,( 1 will c I for a Grout In ion ' r to grouting and a final inspect'00, t Signed X Title: /,T!L� Date: 1.2 (Draw Plot Plan on Reverse Side) f FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspection I Final Inspection Inspection By Date Inspection Vece�vecl Date U CIO1. i Fee IS Due: 13 ANNUALLY El PER UNIT El PER SITE 1:1 EACH EI January 1 & By January 31 ❑ July 1 3 Received By Juiy-31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE q,C ! LESS PRORATION PLUS PENALTY OTHER 4 OTHER i n L< 1-411 �9 /& 3 � l I Received by ate ' Receipt No. Permit No.- .uance Date Mailed Delivered- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 ✓ 1