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ppimationswill BeProcessedWhen Submitted Properly Completed. Be Sure T i T aa� — — FOR�OFF�CE USE; r... 8� pii ation, _ APPLICATION I i r� JIB' 7 tj (For Non-Transferable, Revocable, Su ) 3 4' ENVIRONMENTAL HEALTH IT�UN 18 1980 P wEtl_ (COMPLETE IN TRIPLICATE) =WATER QUALITY p Application ishereby made tothe San JoaquinLocai kealth District for a,permittoconstruct an st ' IY 1ert. dpffiribed.This application is ' made in compliance with San Joaquin County Ordinance No. 1862 and the renes and regulation I Exact Site Address M `+� i rA] A l79 R I Health District. City/Town nf i Owner's Name Thompson Rd. Address phone � City Stock on Contractor's Name Dtl Ets Dri ling CSFp, License#x7792 �g _ L} Business Phone "` Contractor's Address � Emergency Phone 8837-3948 Is Certificate of Workman's Compensation Insurance on FileWit SJLHD? Yes No TYPE OF WORK (CHECK); NEW WELL 11DEEPEN P RECONDITION DESTRUCTION❑ 4 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ xi PUMP INSTALLATION 11PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE /TYPE OF WELL 13INDUSTRIAL CABLE TOOL tt W -•bia�of Well Excavation— 2 © DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 12 11 w ❑1 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �. [� IRRIGATION ❑ GRAVEL PACK 6 _ Depth of Grout Seal n ❑ CATHODIC PROTECTION �❑ ROTARY `? `" `�s� F - ❑ DISPOSAL �._ Type of Grout ❑ OTHER Other Information - ❑ GEOPHYSICAL ., Surface Seal Installed By: PUMP INSTALLATION: Contractor _ h � Type e of Pum _y_ — —p— H.P. PUMP REPLACEMENT ❑ —_._ - ---- . ------- --�-,.-��------ State-Work-Done -y S PUMP REPAIR: ❑ State Work Done ' G DESTRUCTION OF WELL: Well Diameter Approximate Depth . Describe Material and Procedu e' � > jltJ I hereby certify that I have prepared this application and that t ie 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 performanceof the work far 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 calf for G Inspec+ion prior to grouting and a final inspection. - Signed X Title: % f< rr ' Date: 0%/=Ac 1 (Draw Plot Plan on Reverse Side) - FOR DEPARTMEN USE ONLY PHASE Application Accepted By I Za__ rj J 0 U Additional Comments: Date U Phase It Grout Inspection Pflase III Final inspection Inspection By Date Inspection B Datef � -_' a Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 r BASE EXPLANATION BILLING REMITTANCE $ REM€T DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE 1� LESS i PRORATION r PLUS PENALTY OTHER OTHER (h] (2-1 y v � Received by. - ate n Receipt No. Permit No, - Is uance bate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA95201