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r> _ -Applications Will Be Processed When Submitted Properly Cofr,,feted. Be Sure To Sign The Application. - FOR OFFICE USE: APPLICATION` . 1 IA V (For Non-Transferable, Revocable,Suspendable) � ENVIRONMENTAL HEALTH PERMIT PUMA"&WELL ' 1�y �.y. (COMPLETE IN TRIPLICATE) 1�. /fix WATER QUALITY Application is hereby madetothe�a`n� oaquin ocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is made in compliance with,, §�an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address�_S__O CFtP1�Lf.1Q0� �11...ZaO Sof1�eFAQt p City/Town sra.cf(T A.) �a Owner's Name GREAT WFs3 rf w RytL 1EST*Tg R DEuP_1A7K EM Phone I INT. " Address 57115 *3.W.RsAwc, Aus, SWI'P`E, IL City ,`.L"rycrb IJ _ � Contractor's Name tIIaE�.L QyUP {',O, )W—License# � Business Phone q4 L"S3 T 7 Contractor's Address C11MM-M WAI Emergency Phone Is Certificate of Workman's Compensation Insuran a on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑_ WELL ABANDONMENT-[--]., OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT13s��' . r DISTANCE TO NEAREST: Septic TankSewer Lines + Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property p y Line �� Private Domestic Well Public Domestic Well INTENDE=D USE TYPE OF WELL ❑ I STRIAL, ❑ CABLE TOOL Dia. of Well Excavation /0 Yt, w DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casa jZ ❑ IRRIGATION [3 EL PACK Deptof Grout Spat. ElCATHODIC PROTECTION I�ROTARY Typ2ydf�GrV L t 4z,` �El�'t"n+� E] DISPOSAL El OTHER Other Information; ❑ GEOPHYSICAL Surface Seal installed By, V NJ ' PUMP INSTALLATION: Contractor �t Cr Type of Pump :'. H P PUMP REPLACEFIENT: ❑ State Work Done " R r J. PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter =' Approximate Depth Describe Moteri6fand Procedare i I hereby certify that I have prepared this/application and.that the work will be d65-n4 in aecordalice with San Joaquin County ordinances, state laws, and rules and;.regulations-of the%San Joaquin Local Health District; , J"v 1 Rome owner or licensed agent's sigfiature certifies the following:"I certify that in the perform@ of fhe work for which this permit is issued, I shall not employ an.y'person in such'manner as to become subje�t.:.to workman's Cppipensation laws of.California.' 1-1 Contractor's hiring or sub-co t acti gs Is gnat a certifies the following:'I certrf' that in the performance of the work forwhich this J pA�Clll issued, I shall employ personsrsubject to workman's compe"h0ion laws of California." l .. t Ifor utA' tion for to grouting and a final inspection. f�, , ' �s T f� �,n.I T Signed X Title: �F C`"(�sr -ARK Date: JK.�E (Draw Plot Plan on Reverse Sid) - I z FOR D ARTMENT 4SE ONLY PRASE I Application Ajcepted By Dat Additional Comments: NL Pha a II Grout Inspection Phase III Final Inspection Inspectiwi BY'.. f Date _j/y Inspection By Date---`` l .r�ti-f� . l Fee Is Due: ❑= NNUALLY El PER UNIT 1:1 PER SITE El EACH ❑January-1`&'R,�eceived By January 31 ❑ July 1 8 Received By July 31 ' "• �i 1 BILLREMIT ING - REMITTANCE $ 4,--1 BASE EXPLANATION---- AMOUNT DUE � CHECKED DATE `�DliTE REMITTED AMOUNT ,x' I FEE 1 LESS PRORATIONPLUS PENALTY Ik OTHER OTHER C1 Lo a f k Received by Date-- + Receipt No. Permit No. Issuance Date Mailed Delivered T APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ��