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UJ f \z,r L1 to_ UbApplications Will.Be Processed When Submitted Properly Completed.Be Sure To TheApplication. C O1 FOR OFFICE USE: APPLICATION r (For Non-Transferable, Revocable,Sus ndable) PUIt/[PiE�t98i ENVIRONMENTAL HEALTH PERMIT SAN J(_V,C`I ,! , ,�uiLOCAL r11 � (COMPLETE IN TRIPLICATE) WATER QUALITY H Tr! D?STR!C;T ..O Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin 4 ar: V2 and the rules and regulations uin County Ordinance No,._18Q2 ons of the San Joaquin Local Health District. Exact Site Address-a34 _ ff7W Vitt City/Town f_sG,4.00^-) Owner's Name L M i L AJ JX Xa It./D Phone �- Address v City C-i`) Contractor's Name �A) License# lr� Business Phone ra2Ad- Contractor's Address Z0 C /21 a ti Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 14 No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION'❑ }._ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR` •�= REPLACEMENT❑ 0 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ca Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 09 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing + ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal (" ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ 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: ® State Work Done RR,Q bAl�ut u f r 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." ` Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this I permit is issued, I shall employ persons subject to workman's compensation laws of California." I W1111,4011 for a Gr Ins tion prior to grouting and a final inspect Signed X Title: Q '�'Z -:� Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By t•�' CJ Date Additional Comments: Phase II Grout Inspection Kasell nal Inspection Inspection By lo Date InspectioZeived Date Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH 1:1 January 1 By January 31 [3 July 1 8 Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE s 4S ti 5 LESS PRORATION PLUS PENALTY OTHER OTHER 4, (0� Received by bateL Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201