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MATE) APPLICATION 0,r Non-Transferable, Revocable, Suspendable). tJ�,A ENVIRONMENTAL HEALTH PERMIT In ' , elf _L SAN JC., (N&1 WATER QUALITY HEALTH DIST PICT Application is hereby made to the 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 Ordnance No. 1862 and the rules and regulations of the San Jgaquin Local Health District. Exact Site Address /2 67 40 //,f tg (, City/Town Owner's Name L /' 1 Qr` �t�'�c/n D Address 2Co7DO Phone L�-=- /1nWL"L City O(� Contractor's Name �a rLo y1P/ �y.l_tr/„�, Licenseif 2-'� Business Phone 2 - Contractor's Address 30 O �I(f!'-,off Emergency Phone CP Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo TYPE OF WORK (CHECK): NEW WELI.� DEEPEN 11 RECONDITION DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank l d 0 f Sewer Lines 1C)OF Pit Privy Sewage Disposal Field 100 '7C- Cesspool/Seepage Pit -- Other 1 Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 1 f� 6❑{DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing O OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I (do PO IRRIGATION RAVEL PACK Depth of Grout Seal _S—Oy ❑ CATHODIC PROTECTION OTARY Type of GroutIt l ❑ DISPOSAL ❑ OTHER Other Information Ua to Ily OWN�Pk ❑ GEOPHYSICAL Surface Seal Installed By: c)wnw/r- PUMP INSTALLATION: Contractor Type of Pump H.P. () I PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth i41IIIIA-1V C-31 Describe Material and Procedure I 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. Home ownerorlicensed 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." W 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 for a Grout Inspec lon prior to grouting and a final inspection. r Signed X � - `� o ' Title: y.<r/h-cam, Date: `t L (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I By�I\�I`�\ �} Application Accepted By ` , , ai� O� Date Additional Comments: II Gro nspection Phalle III Final Inspec'on Inspection By 'Date Inspection By L., Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 13 July 1 &Receivetl By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNTDUE CHECKED DATE - DATE REMITTED AMOUNT FEE Lf { LESS v PRORATION - PLUS — PENALTY OTHER OTHER ,( Received Ity Date Receipt No. Pelmul No. Issuancepate I Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201