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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: ;j APPLICATION - / �-� � `��'�' '% (For Non-Transferable, Revocable,Suspendable) P&"WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) �' WATER QUALITY Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is made in compliance with San Joaquin County Ordinan o. 1862 and the ru s and regulations of the San Joaquin Local Health District. Exact Site Address �C 7 �ii 7�. ��}} G , ) City/Town �Y�G Owner's'Name C ` o,d 4 i 5a Ake' = Phone Address """es `' '" _ City Contractor's Name JPWeS r SL�cense# `3GH4�- Business Phone. t Contractor's Address /t( .- g fnf37 ` �R y'��Emergency Phone 6�w Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): - NEW WELL w DEEPEN ❑ RECONDITION O DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ s' f DISTANCE TO EARSjT: Septic Tank J Sewer Lines 75a Pit Privy r; Sewage Disposal Field Cesspool/Seepage Pit Other AY 174N�A"f . Property--L-ine- -,9� �Private-Domestic Well 0 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL - -_r__❑-CABLE TOOLDia.-of�Well Excavation DOMESTkC/PRIVATE I 11 DRILLED Dia. of Well'Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing s AW - ❑ IRRIGATION GRAVEL PACK f�Depth of GrSeal. El CATHODIC PROTECTION 11 GRAVEL CTION ROTARY Type of Grout Q- ++ ❑ DISPOSAL I, ❑ OTHER Other Information ❑ GEOPHYSICAL - ` Surface Seal Installed By: 2<r4A S ' PUMP INSTALLATION: Contractor / ! i Type of Pump—, .. •� 6 H.P. J PUMP REPLACEMENT: H ❑ State Work Done { t PUMP REPAIR: + ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Y I Ap roxi to Dept f Describe Material and Procedure [ � M t _ r V Ile I hereby certify that I have prepared this application and that the work willbe done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health;District. r Home owner or licensed agent's signature certifies the following:"I certify that'in tyle 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." Contra-tor's hiringorsub-contracting si nature certifies the following- 'I certify thatlin the performance of the work forwhich this t ff 9 t9�' Y � p � permit "iib issued, I shall employ persons subject to workman's.compensation_law.s.of California." I I will call fo'r a Grout Inspection prior to grouting and a final-inspections Signed X . ati. . Tit le: Dater (Draw Plot Plan on Reverse Side)`.' i FOR DEPARTMENT USE ONLY PHASE i Application-Accepted By Date Additional Comments: P e rout Inspection Ph a inal Inspection ` y Date Inspection.B - 0' W _ Inspection BY Date 1Sp it I Fee Is;Due: ❑ ANNUALLY ;`❑ PER UNIT ❑ PER SITE _❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 G r REMIT BIDING REMITTANCE $ BASE ";k EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE t LESS PRORATION PLUS II - PENALTY OTHER ,... — -- -•+,. _.....y.._-,...ti..,,.-.,--�- - �_-_ �.��.,-.^. -- x..,.- _ _ ,, .. ""- OTHER Received by - Date Receipt No. --PermitlVo._� - - - .Iss ante D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 'I