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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. _71, x FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT ,,NNED WELL F (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto 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 regulatipns of.the San Joaquin Local Health District. Exact Site Address- rata Rd City/Town Stockton i t Owner's Name. Ri Ck Arata _ Phone Work 931--1470 Address - City Stockton ( Contractor's Name r_1rk ws*i-1 ._&qui pilie -t - License# '371560 Business Phone 2-5597 # Contractor's Address Emergency Phone N Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN 13 RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ i DISTANCE TO NEAREST:- Septic Tank 50!.-- Sewer Lines Pit Privy 1 F Sewag6 Disposal Field Cesspool/Seepage Pit Other [� Property Line Private Domestic Well Public Domestic Well 1! INTENDED USE TYPE OF WELL �\ ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10 5 81I DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing 6 $'I ❑ DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing 2 Steel ❑ IRRIGATION 13GRAVEL PACK a Depth of Grout Seal O r ❑ CATHODIC PROTECTION Ek ROTARY Type of Grout Bentonite 11.DISPOSAL ,.O,OTHER Y Other Information h ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: .Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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 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." C Contractor's hiring or sub-contracting signature certifies the following:"I certify 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." fw' all for a Grout Inspection prior to grouting and a final inspection. Signed X g Title: �� Date: (Draw Plot Plan on Reverse Side) ' FOR DEPARTMENT USE ONLY PHASE Application Accepted B Date of Additional Comments: _ " a II Gr 1 Inspection Phase III Final Inspection Inspect o By "{' C Date J - Inspection By 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 BASE EXPLANATION DATEAMOUNT UUE CHECKED - DATE REMITTED AMOUNT FEE 3 .f – - sf LESS PRORATION - PLUS PENALTY OTHER OTHER Received by Date - Receipt No. Permit No. - -9-.IA..a. ate Mailed Delivered .� APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201