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i. Applications Will Be Processed When Submitted Properly Completed.%�4;ureo S, n The Applicati U , FO OFF-CE USE: - APPLICATIONC + 5 1979 (For Non-Transferable, Revocable, Suspenda�e)N �� f p&WELL 21,41 ENVIRONMENTAL HEALTH PERMIT)��aL r oiSTRd'"� v ICT (COMPLETE IN TRIPLICATE) WATER QUALITY ` Application is hereby made to the San Joa�g/y�iin��'9�at H th trict fora permit to construct and/or install the work herein described.This application is made in compliance with San JoaqugC�IJr1Zy�rdiM 862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addresslr ?,4cc- Qa(/ tv- �E JC1A &M S' City/Town 7Z .LV Owner's Name _AZ17-- MAW-d Phone Address 'A/0AaDP SS City Contractor's Name CA4"M-0e. DjEUJAIG rp . License#L2Z2l-21. Business Phone �32-7 32 Contractor's Address (JO S. KiLRoy 7(1P`Q(_L Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJl_HD? Yes ')4, No TYPE OF WORK (CHECK): NEW WELL% DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRO ) REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy O1 Sewage Disposal Field Cesspool/Seepage Pit Other a?(� Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation—& DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN` Gauge of Casing 'f�VG 14ZQ i ElIRRIGATION 1GRAVEL PACK Depth of Grout Seal 6-0 ❑ CATHODIC PROTECTION F %ROTARY Type of Grout SUTVAUZZ DISPOSAL ❑ OTHER Other Information r ❑ 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 Y t • ` Describe Material and Procedure a I' I hereby certify that l 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. I. Homeowner or licensed agent's signature certifies the following:"I certify that'in the performance of the work forwhich 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 0 permiit7is issued, I shall employ persons subject to workman's compensation laws of California." I will call f r a Grout Inspection prior to grouting and a final inspection. :,- _ ...:•..�...�..µ Signe ,X Title: Date: j (Draw Plot Plan on Reverse Side) } ` PHASE I FOR D ARTMENT USE ONLY /J� ; Application Accepted By Date Q S Additional Comments: Phase 11 Grout Inspection ? Phase I Final Inspection / �r R spection By Date Inspection By L Date Fee Is Dile: ❑ AN ALLY - ❑ PER UNIT PER SITE x❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 - - a.:, ; BILLING REMITTANCE $ REMIT ASE EXPLANATION AMOUNT DUE CHECKED -. - DATE DATE REMITTED AMOUNT FEE PR RATIO Y OTHER - 7 ° `7�i•— l��s S ��s�7y I[ � RectiPed by Date - Receipt No. Permit No. – Issuance Date - Mailed Delivered - .� i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201