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Applications Will Be Processed When Submitted Properly ComplerWAei.Sure:,To�'Sign The Appllcat s �J FOR OFFICE USE: APPLICATION h (For Non-Transferable, Revocable,Sus, le)lDf-� Ap&WELL ENVIRONMENTAL HEALTH'PERMIT M,QUALITY (COMPLETE IN TRIPLICATE) WATER �wr`�� ,,��',. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inIVl't1Ye work herein described.This application is made in compliance rywith San.Joaquin County Ordinan ce No. 18 nd the.rules and regulations-of the San Joaquin Local Health District, Exact Site Address l�/-rl V_ r IL. r u.�a�00,A City/Town F4-0C_V, 0)i)" Owner's Name L�� £" ' " "' Phone" Address - CityLI- Contractor's Name �. �` j1LfZ +`� " License# 4,Q slness Phone —ti o p, 1 Contractor's Address - `r ''sir', , Emergency P o e;1_ vim'[�-t� Is Certificate of Workman's Compensa on Insurance on File With SJLHD? Yes No i TYPE OF WORK (CHECK): NEW WELL'❑^"DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field '"Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well - INTENDED USE TYPE OF WELL ❑ IND STRIAL ❑ CABLE TOOL i Dia. of Well Excavation O DOMESTIC/PRIVATE ❑ DRILLED-" -�'^' " -Dia.-of Well Casing = ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i ❑ CATHODIC PROTECTION ❑ ROTARY _.-._ Type of Grout f ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type.of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done i PUMP REPAIR: 29 State Work Done I� DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure m - 5 •' r•4j � r i I hereby certify that I have prepared this application and that the work will'Ie done io accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j 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 certify that in the performance of the work forwhich this permit is issued, l shall 'employ persons subject to wotkman's'compensatiori laws of California.""-- "" s for a Grout Inspection for to ZtZnd a final inspection. is ' AJ Signed X zot= Title: . Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 4 Application Accepted By - - Date Additional Comments: Phase 11 Grout Inspection h III Final Inspection Inspection ByDate _ Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 BILLING REMITTANCE - $ REMIT BASE EXPLANATION AMOUNT DUE - CHECKED DATE {LATE REMITTED AMOUNT PEE zv O��.--- LESS PRORATION PLUS PENALTY ' OTHER E OTHER _ 4T 4-;;i- D-a Received by Date Receipt No. Permit No. Issu nce Dalte MailedDelivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 ,F