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Applications Will Be Processed When Submitted Properly Completed. Bet�To Sign TheAppliCatiow LiuFOR aFFIC P+,SE: APPLICATION MAY 21 19 0 ,, wc. (For Non-Transferable, Revocable, Suspendable) P (J MP&WELL ENVIRONMENTAL. HEALTH PERMIT SAN JOAQUIN Lo', L (COMPLETE INTRIPLICATE) WATER QUALITY HEALTH DISTRI -� Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescn t�d.Thisapplicationis I made in compliance with San Joaquin County Ordinance No. 1862 arld the rules and regulglons of the San Joaquin LoctI Health District. i Exact Site Address t�+� - 5� t''� �� 0 1 � I City/Town E S is i Owner's Name Phone � r .-r1� Sn L0.`rvC1 �rr�� iZ[� City ccvc� Address i Contractor's Name (4M License#t l� Business Phone_, Contractor's Address C� fin .,a vol&-J Emergency Phone `J�o ra` 5 /l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , WELL CHLORI ATION ❑ WELL ABANDONMENT ❑ OTHER C1 PUMP INSTALLATION 11 PUMP REPAIR 1 REPLACEMENT DISTANCE TO N� REST: Septic Tank - Sewer Lines Pit Privy Q�. ;1 Sewage Disposal Field Cesspool/Seepage Pit Other r %rte Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal \k ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ` 13 DISPOSAL 11 OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: �r PUMP INSTALLATION: Contractor _ l Type of Pump 1r� "AYE�Vr t _ H.P. �J PUMP REPLACEMENT: State Work Done Ci.J -`U'r O LJ C, PUMP REPAIR: State Work Done G DESTRUCTION OF WELL: Well Diameter Approximate Depth 4 Describe Material and Procedure j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I 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 cer=tify 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 Grout Inspection prior to grouting and a final inspection. e. 5L. poet 2 Date: Signed XTitle' R?eelselde) (DrawPlotPlan on FOR DEPAR MENT USE ONLY PHASE I /l Application Accepted By Date Additional Comments: k Phase II Grout Inspecti n e III Final Inspection 1}r Inspection By Date Inspection - Date k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �PEH SITE ❑ EACH ❑ January eceived By January 31 ❑ July 1 &Received By July 31 REMIT I BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS t PENALTY a' OTHER t OTHER _ / Permit No, Issuance Date -ailed_ delivered , Received by Date Receipt No �..�.__�•- r APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICEs 0601 E.HAZELTON AYE.,P.O.Bax 2a STOCKTON, ;C, ..