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Applications Will Be Processed When Submitted Property Completed. Be Sure To Slgn The Application. FOR ---Y I — Ce USE: APPLICATION Le, ' x_ (For Non-Transferable, Revocable,Suspendable) UMP&WELLS ' ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address l � �9 � Af cL City/Town k11 G �- Owner's Name ,S. r g /-- ; 6 ce T _ Phone Address /C' 4,- 45;nX. 71 9 - City Contractor's Name ✓> ' License#J-4L 91-2z? Business Phone2- /6 7 Contractor's Address c.2©c Q ,,V, So Aego�S le�s,Emergency Phone N'�, fi e. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No >:S,- TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - WELL CHLORINATION ❑ WELL-,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /�u^JC Sewer Lines IUo Ne� Pit Privy a. 1e- 1 Sewage Disposal Field /Voe! Cesspool/Seepage_Pit o'm/j a we, Other 43/V,0 /tAJ Property Line%747 I Private domestic Well t�f V Public Des'Le-Well .d e, �r - INTENDED USE TYPE OF WELL - �- ❑ INDUSTRIAL i iCABLE TOOL i]la:"af-Well-Excavaflon DOMESTIC/PRIVATE- ❑ DRILLED Dia. of Well Casing E] DOMESTIC/PUBLIC.. ----,,x ❑ DRIVEN Gauge of Casing I- av oC� ❑ IRRICATIOtJ=�, x ;, GRAVEL PACK a- depth of.-Grout Seal ❑ CATHODIC.PROTECTION, ❑ ROTARY Type of Grout k ❑ D1511OSAC A ElOTHER Otfier Information ElGEOPHYSICAL` r Surface Seal Installed By _ n PUMP.INSTALLATION: Contractor. / .0 -/1"- Type of Pump PUMP REPLACEMENT: Y ❑ State Work Done V { PUMP REPAIR: ❑ State Work Done 4 f- 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_Distri.ct _ Hame owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit is issued, I shall not emp�Ioy-any-person iri skh manner'as to-become-subject.to-work mans=compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation=laws of California." r 1 will call for a Grout)Inspection prior to grouting and a final inspection. h Signed'X �. Title: 0-6 - J_ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted BY L-1 l C'0L Date�3 Additional Comments: tthll Grout inspection h 111 Final Inspection Inspection By Date rl Inspection By L2- Date Fee Is Due: ❑ ANNUALLY; ❑ PER UNIT_` ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT SASE EXPLANATION. AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT FEE Ir 7,!i5bA ` _g LESS PRORATION PLUS PENALTY s r OTHER ' OTHER f Received by 5 Receipt No.i t Permit No. Iss ance Date Mailed Delivered e APPLICANT—RETURN ALL COPIES TO: _ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201