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ApplicationsWill BeProcessed WhenSubmitted PropertyCompleted. Be� e �nJ heTobica(fj<bn.� I y 4 FOR OFFICE USE: APPLICATION )@ It Ly (For Non-Transferable, Revocable,Suspenda ENVIRONMENTAL HEALTH PERMIT in JgWP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 1>jjN L-�C�s� Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or inst t'� mT This application is �w made in compliance with/San�1Joaquin County Ordinance No. 1862 and the r lesoand regulations of th raquin Local Health District. Exact Site Address 44%�l`a �, { [-,f�L _ k0, City/Town C�� .oi Owner's Name _ ' Phone - }� 7c Address ra tyaU ,may City Z.4,C 191C)AI Contractor's Name License#2zayo Business Phone_�� t 7 Contractor's Address _,4DL3 t'i119 , Emergency Phoner7 d-19 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes / ill- No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 2t- REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ T Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL C1CABLE TOOL Dia. of Well Excavation IN 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 i Other Information f\ ❑ GEOPHYSICAL Surface Seal Installed By: Cd PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 10 State Work Done ' 11; Z MIX DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call f r a Grout Insp Gtion pr'or to grouting and a final inspeI Signed X Title: ✓C�2�`/1�[G� Date: ��_ (5 (Draw Plot Plan on Reverse Side) FO DEPARTMENT USE ONLY PHASE I Application Accepted By4--ItDate J J Additional Comments: Ph se II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date ` 1 — Yly✓ *I_rrr Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED AMOUNT FEE L Ll S LESS PRORATION PLUS PENALTY f OTHER OTHER Received by Da16 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 .