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/ Applications Will Bal ocessed.When Submitted Properly Completed. Be 0lo algn Ine Nppricauv,,. _ FOFt -RcE usE: APPLICATION (For Non-Transferable,Revocable, Suspendable) /,4.10,f` (For &WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (COMPLETE IN TRIPLICATE) -" 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 Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. I.1 Exact Site Address too L � � /`�+ u A-e./. S A -City/Town t/ Phone Owners Name - City S'eLs Address - License 11/93Business Phone .Contractors Name,! - - - -- - _ Contractors Address r Emergency Phone Ir Is Certificate of Workman's Compensation Insurance on File With LHD? Yes No ,' TYPE OF WORK(CHECK): NEW WELL 13 DEEPEN❑ RECONDITION❑ DESTRUCTION❑ .. ny WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION 13 PUMP REPAIR yr 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 _ IR INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE _ ❑ DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 4 ❑ GEOPHYSICAL ' Surface Seal Installed By: PUMP INSTALLATION: Contractor H P �J s t Type of Pump i, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 9 State Work Done ^ t Approximate Depth DESTRUCTION OF WELL Well Diameter r 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 r 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 performance of the work forwhich thispermit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 4 Contractor's hiring or subcontracting 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 call for a Grout Inspection prl to gro t g and a final inspection. 1 �y tile. Date: Signed X (O raw Plot Ian on-Reverse - •"' FOR DEPARTMENT USE ONLY PHASE'I .Date�'- - Application Accepted By Additional Comments: _ _ _ -- " Phase II Grout Inspection r Phase 111 Plnal Ln paallon cc�� Date Inspection By - Date 7 l� a"• Inspection By - �. Fe!IS Dul: IJ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja m,I'&Received By January 31 Ll July 1 a ReceivedBy31 BILLING REMITTANCE S. AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE 'REMITTED AMOUNT FEE b LESS ' PRORATION O PLUS PENALTY OTHER OTHER Received DY Dale Receipt No. Permit NR. Mailed erica M Deilvere� 1897 E.HA2ELTON AVE,P.O.aaS 1009 `TOO&ON,CA 99901, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `