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_ ..�� Applications Will Be Processed When Su�bmittgd,Properly Completed. ure"To Sign The Applicatia6.� w f oR OFFICE USE: j APPLICATION . 1979 d (For Non-Transferable, Revocable, Suspentlable) ENVIRONMENTAL HEALTH PERMIMAN JOAQUIN LB S&WELL I (COMPLETE IN TRIPLICATE) I' WATER QUALITY HEALTH DiS��€CT Application is herebymade totheS t'i Joaquin Local Health District fora permit to construct and/ur install the work herein described.This application --C made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. . ! Exact Site Address I l) ��I �_ L��-I� I }1 C i.ty/Town --"MJ44 Owner's Name b I """ Phone 14 "5r 3C'7 o Address I �� Gf!N C 1V., -T�— -V City Contractor's Name FnAo��'� -TN ni License#W'l � Business Phone Contractor's Address;zq'7_ Ix , & ffiZ TBPL4 , Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ }f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ k DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other .q: Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia..of Well Excavation V ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ! ❑ OTHER Other Information ❑ GEOPHYSICAL I Surface Seal Installed By: �r PUMP INSTALLATION: Contractor. 1' j I I Type of Pump H.P, " I PUMP REPLACEMENT: ❑ State Work Done - PUMP REPAIR: I State Work Done DESTRUCTION OF WELL: I i Well Diameter ry _ Approximate Depth I ' Describe Material and Procedure I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws1and 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 otthe 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 snub -contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall lll employ persons subject to workman's compensation laws of California." I will c for a Grout lilt!s ti prior to outin and a final inspect Signed X Ilf Title: Date: Ij (Draw Plot Plan on everse Side) ' ORD ARTM USE ONLY I _ PHASE I I : /�j Application Accepted By I `r Date 1 Additional Comments:- TIMI 1 Phase II Grout Inspection Ph e f final Inspection Inspection By 1A! Date Inspection B Date Fee Is Due: ❑ ANNUALLY !I' ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Rece�ved By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASED EXPLANATION DATE DATE REMITTED AMOUNT DUE AMOUNTCHECKED FEE ?�! p � LESS 'I�1 PRORATION BA PLUS PENALTY I f OTHER II` OTHER II�. I. II `7- 11�f /�� Received by Dateki Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ISM E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA JNA _.._.r.•- .