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r.� ... �. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.� Y� �l'�'FCra OFFJCE USE: APPLICATION / # (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMA&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is t made in compliance with San J�uinCountOrdnance No. 1862 the rules and regulations of the San Joaqu�Loal Health District. Exact Site Address . (� City/Town_� Owner's Name L bi Phone _ �" � Address ��d M►1 OSTji _ City Contractor's Name �'.� �.1. ►�1t}'l 'r License# 1 SaCa Bus- ess Phone Contractor's Address O Emergency Phone Is Certificate of Workman's Compensation Insun File With SJLHD? Yes�. No E TYPE OF WORK (CHECK): NEW WELL r a oDEEPEN El RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El 'i REPLACEMENT❑ �(' ( t j DISTANCE TO NEAREST: Septic Tank 7 b Sewer Lines 5_0 'If" Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ 1 USTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED I,, - G k __ bia'of WeILCasing ❑ DOMESTIC/PUBLIC ❑ DRIVEN�"� Gauge o?-Ca-sing -- El - asing "'""" ' ❑ IRRIGATION ❑ VEL PACK , Y� Depth of Grout Seal �d ❑ CATHODIC PROTECTION LS ROTARY 4 Type of Grout ,. Y ❑ DISPOSAL ❑ OTHER _ Other Information ❑ GEOPHYSICAL —_�;_,,,,._Surface-Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump s '� H.P. . PUMP REPLACEMENT: ❑ State Work Done" PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth + Describe Material and Procedure I` hoYeby certify that I have prepared this applicatioaand that the work will be done in accordance with Sast-Joaquin County . ordinances, state laws, and rules and regulations of the San Joaquin Local Health District!'_ j ,_,,..��Home owner or licensed agents signature certifies the_following:"I certify that in''t-e:perforrnance 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 compensatiotl,laws of California." Contractor's hiring or sub-contracting.signature certifies the following: I-certify that in the performance of the-work for which this pit is issued, I shall employpersons subject to workman's compensation,lays of California." j C. I wit calt.for Grow/Inspection pr r to grou ' g and a final inspec(ion. + } -.� Signed X` ✓ ~caC, �C/ �— Title: l�Y1W ujo,.L _ Date: �.O a ;f (Draw PlotrPlan on Reverse'Side) `- a DEPARTftl1ENT USE ONLY Application Accepted By— } PHASE I /��..; _ Ane-c . 07 Date 6-1 a �1 Additional Comments: Phase 11 Grout Inspection Phase ll Final Inspection Inspection B Date Inspection By # Date Fee Is Due: ❑ Ari ALLY ❑ PER UNIT ❑ PER S4E ❑ EACH ❑ January 1 8 Received By.J'alnuary 31 ❑ July 1 8,Received By July 31 a I BILLING REMITTANCE ,:.fr$"�^ ++ ' REMIT BASE EXPLANATION AMOUNT DUE CHECKED +" �t,DATE REMITTED AMOUNT FEE ��1I' --.�.,.-.....,_,.."...:-t_.t.—.. - _ .T,•.;�--.,,,_.�,.,,.-�,,._ ,•,:*...--,w,r.r-�.,�„ p LESS PRORATION PLUS PENALTY OTHER OTHER i Received by Date t Receipt No, Permit No. Issdiance Dae I Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21309 STOCKTON,CA 95201 ?