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^' . Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FORrOFFICE USE:- ''v'�p ,) APPLICATIONy x s� (For Non-Transferable, Revocable,Suspendable� p & ELL G a ENVIRONMENTAL HEALTH'PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY, Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install thew ork herein described.This application is made in compliance with S n Joaquin County Ordinance No. 1nd the rules and regulations of the Sa Joaquin 862 Local Health District. Exact Site Address City/Town4 ' .P Q° Owner's Name An r47 Y j dG 6ui Id Phone Address k City c� e, Contractor's Name License#3 f� ��-3 Business Phone ,�6 Contractor's Addres Pio .. o, 21� A Z . Emergency Phone c- Is Certificate of Workman's Compensation Insurance_on File With SJLHD? Yes - No _ TYPE OF WORK (CHECK): NEW WELI,1 •}DEEPEN ❑ RECONDITION❑ ` -- DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ r REPLACEMENT❑ I ,A DISTANCE TO NEAREST: Septic Tank 5 Sewer Lines �� Pit Privy _ AJox11l -- fir- ',Sewage Disposal Fi-I Ield+ Cesspool/Seepage Pit /Vc�.V Other ,Property Linkl%.. Private Domestic Well A204/EPublic Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL" , CABLE TOOL Dia- of Well Excavation /a DOMESTIC/PRIVATE ❑ DRILLED -Dia:.of"hlell Casing 5Wt ❑ DOMESTICIPUBLIC— - �❑ DRIVEN Gauge of Casing 7 o. I f V"1 ❑ JR Rt IGATION— GRAVEL-PACK, Depth.of-Grout-.Seal-—,-IM— ' El CATHODIC PROTECTION ROTARY Na Type of Grout r13 DISPOSAL x ❑ OTHER Other Information !_ EI GEOPHYSICAL Surface Seat Installed By: �'F PUMP,INSTALLATION: Contractor _ I f. Type of Pump f—Mi; ea u - H.P. PUMP REPLACEMENT: ❑ State Work Done; PUMP REPAIR: ❑ State Mork Done DESTRUCTION OF WELL: Well Diam ter,. Approximate Depth Describe Material"a d"P,roceldure t ! hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County t ordinances, state laws and ring and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit ..` +i is issued, I shall not employ any person in such manner as#o become subject to workman's compensation laws of California." I f + Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this t 3. permit is issued, I shall employ persons subject to workman's compensation laws of California." t" •' I wt all for aGrout Inspectio prior to grouting and a final inspectlon. { f� Signed X a Title: [.O�d t'+�7 � Date: ✓' (Draw Plot Plan on Reverse Side) ` FOR DEPARTMENT USE ONLY ( i i� PHASE I ® � Date } i f Application Accepted By Additional Comments: _ Phe e N Grout Insp on Phase III Final Inspection yam- Inspection Bye Date - /��y r Inspection By Date .Jew/ - Fee Is DUe: 11 ANNUALLY [3 PER UNIT ❑ PER SITE' El EACH ❑ January 1 &Received By January 31 ❑ J-1 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT'DUE CHECKED DATE DATE REMITTED AMOUNT FEE E. Q LESS { PRORATION F i ; PLUS -7 PENALTY 1 OTHER 1. OTHER y^ - ctx— '7, 2 ' g `-Received by Date - -Receipt-No- Permit No. Issuance Date Mailed - Delivered - J APPLICANT--RETURN ALL COPIES To. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _.