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IWOU Prope Applications Will Be Processed When SuAPPLICATIONpfeted. Be Sure o Ign �`� t_4 � a...a UU • FOR OFFICE USE: ,& _ y '.w i (For Non-Transferable,Revocable, Suspendable) [} Q ENVIRONMENTAL-HEALTH PERMIT WATER QUALITY rt , SM!,_i0, ,QUIN LQ + (COMPLETE IN TRIPLICATE) r 5R_ Application is hereby madeto theSan Joaquin Local Health Districtfor a permit to construct-and/or install the work herein d�s�id�tli��1i f(��s {• made in compliance with San Joaquin County Ordinance.No. 1862 and the .rules and regulations of City/TownSan Joaquin Local Health District. Exact Site Address 20720 Sutliff phone $38, 7147 p. Owner's Name p.0. P_, 36 city Ripon' Address ..52-2-9027 1 Stanislaus Pru>tp,,Machinery: & License# 7Q �� Business Phone Contractor's Name eStp. 522-902 Conirattat� F.�. � ' Emergency Phorie } X No r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - n TYPE OF WORK (CHECK): NEW WELL❑DONDEEPEN ❑❑ OTHER ITI PUMP INSTAL AT ONX PUMP REPAIR❑ C WELL CHLORINATION ❑ WELL REPLACEMENT❑ I Sewer tines Pit Privy DISTANCE TO NEAREST, �• Septic Tank Cesspool/Seepage Pit Other T t - Sewage Disposal Field Public Domestic Well Property Line Private Domestic We INTENDED USE TYPE OF WELL Dia. of Well Excavation 11 INDUSTRIAL 11 CABLE TOOL ❑ DRILLED Dia. of Well Casing I 17-DOMESTIC/PRIVATE Gauge of Casing I 11DOMESTIC/PUBLIC 13 DRIVEN ❑ GRAVEL PACK Depth of Grout Seal El IRRIGATION ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t 13 DISPOSAL ❑ OTHER Other Information Surface Seal Installed y: Stanislaus pLunp, Machinery & Construction Corp. ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor l fOS H.P. Type of Pump GrUI1C� PUMP REPLACEMENT: ❑ State Work Done i j PUMP REPAIR- ❑ State Work Done - ! Approximate Depth DESTRUCTION OF WELL: Well Diameter Describe Material and Procedure k hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. "I certify that in the performance of the work forwhich this permit Home owner or licensed agent's signature certifies the following: become subject to work is issued, l shall not employ any person in such manner as to man's compensation laws of California." I 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." I will calf for a Grout inspection prior to grouting and a final inspection. Date: 74882 Title: M, Signed X (Draw Plot Plan on Reverse Side) G FOR DEPARTMENT USE ONLY ! PfiASE I G_A� O Date - Application n rt Application Accepted By z3 • Additional Co 1141ments: - ase fll Final inspection Phase 11 Grout Inspection Date f Inspection By Date Inspection By ❑ R SITE ❑ EACH ❑ January'l &Received By January 31 ❑ Juky 1 &Received By July 31 Fee Is Due: PER UNIT PER[ "ANNUALLY ❑ REMIT REMITTANCE $ AMOUNT DUE CHECKED BILLING REMITTEE AMOUNT - BASE EXPLANATION- DATE DATE t � 1 FEE •�i - I LESS PRORATION S PLUS PENALTY, OTHER i OTHER Received by Dat Receipt No. Permit No. Issuance Dale Mailed Delivered 1601 E.HAZELTON AVE.,P.O.Bax 2909 STOCKTON,CA 95201 . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES