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Applications Will Be Processed When Submitted Properly Completed. Be To Sign The ApfJjra(ipn. FOR OFFIE USE: APPLICATION Nov ,y(O 1 -�� (For Non-Transferable, Revocable, Suspendable) AQu1W30CAVE LL ENVIRONMENTAL HEALTH AT I H p�s5ilicf (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is V made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address /26-20 �Qt/OA/ City/Town TPACi,/ Owner's Name Aft►. TQ/2P,ES Phone p3d__2902 ~ Address saAfET City V Contractor's Name License#SX26_1 Business Phone 412 7W1 Contractor's Address WO S LLffq4 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4 No TYPE OF WORK (CHECK): NEW WELL% DEEPEN ❑ RECONDITION DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ ^' DISTANCE TO NEAREST: Septic Tank W P7*- Sewer Lines Pit Privy -` Sewage Disposal Field /00 Or- Cesspool/Seepage Pit Other N Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL Af ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _/_l � 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �~ R, DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -pvG 140 ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 44-0 E77• ❑ CATHODIC PROTECTION ROTARY Type of Grout Zftr 172 ❑ DISPOSAL ❑ OTHER Other Information N ❑ GEOPHYSICAL Surface Seal Installed By: i 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. Home owner 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, I shall employ persons subject to workman's compensation laws of California." �I will call f a Grout Inspection prior to grouting and a final inspection. Signed X &61& Title:e7 (Draw Dater 7�S �j J (Draw Plot Plan on Reverse Side) F RDE ARTMENT USE ONLY `� �'/7g P.JLJL PHASEI Application Accepted By Date Additional Comments: yi4� Phase If Grout Inspection ('Ph�a III Final Inspection Inspection By - Date Inspection By Dat ( Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13PER SITE 13EACH ❑ January 1 8 Received By January 31 ❑ J 8 Received By July 31 14 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION . PLUS PENALTY OTHER OTHER Received by Date Receipt No, Permit No. Is ante Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2909 STOCKTON,CA 95201