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{ a Applicetlons Will Se Process-d When Submitted Properly Completed. Be Sure 7'o Sign The Application. OFFICE use-- APPLICAT101"id �r (For Non-Transferable,Revocable,Suspendabie) ) L FU,'Ar`&WELL 1I ENVIROP NWNTAL HFA—i H PERMIT (v0R,4PL_TE IN TRIPLICATE) WATER QUALtfY gll AcD -n!ionisherebymadetothn.SanJoaquinLocalHealthDlstrctforapermit ioconstructand'orinstill rhework herein describe; This application is 4r compliance San Joaqui oun!y Ordln ce No 16<;rn the ri;rps and regulatio,n�of the San Joa uin Local Hearth District. - r /wrS}' i r Ex: a Address C�ii' � �1c � -'(4 C cJ/�!J ��/r, SC4!yo un _ 2�� 4 - Phone �P —p "j-f v{ License#3O�0_G S� Business Phone C-,.,. .tor's Nam y2�iiv_ T`'- c C n' actors Address -. -- �C Y�Rry Phone P.3 rO ---- s -fi- Cer ficate of Workman's Compensation Insurance on File With SJLHD? Yes L� No TYPE 0.r WORK (CHECK). NEW WELL LA` DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N,'E_i LORINA ION IJWELL ABANDONMENT ❑ OTHER ❑ PUN^P INSTALLATION PUMP REPAIR❑ t a_,.. _".DENT❑ .E TO NEAREST: Septic Tank (f��-, Sewer Lines 17-�— Pit Pivy / ' ____ So" Sewage Disposal Field //b-T-- — Casspo 'r>,npage Pit`GLr'^ i Other Property Line. _ Private Domestic Well - Public Domestic Well - INTENDE=D USE TYPE OF WELL INDU:'TRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DO"aE STIC/PRIVATE ❑ DRILLED Dia. of Well Casing 67-71-.-1,1FSTIC/PUBLIC ❑ DRiVEN Gauge of Casing ---- ❑ c- G\TION ❑ GRAVEL PACK Depth of Grout --- HGDiC PROTECTION NARY Type of Grout L �OSAL ❑ OTHER Other Information --��f� -t, Q�=- - OPHYSICAL / --Surface Seal Installed By: ;fiSTALLATlON: Contractor! Type of Pump PUMP^EpLACEME*dT: ❑ State Work Doll 1 PU`.' =PAIR: ❑ State Work Done D_ JICT(ON OF WELL: Well Diameter -- -- - App oximate Depth -.-- -- --- c~- Describe Material and Procedure I hereby certify that I have prepared this application and 'hat the work will be done in accordance w ;an Joaquin Coun't ordinances, state laws, and 'ules and regulations of the San Joaquin Local Health District. €' Home owner or iicensed 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 or California.- i Conhiring or sub-contracting signature certifies the following:"I cel tify that in the performance of the work forwhich this Cori permit is issued, i shall employ per ,-1 sijbject to workman's compensation laws of Califirnia." F I I ,'!I cal!for a Grout Ins �i n \? grouting and a final inspection s \ ?_ �� - Title: -LL =_V_l�_C ` Date --3-J_- 1 D=am------ -- raw Plot Plan sn Reverse Side) ; i FOR DEPARTMENT USE ONLY -�fiASE 1 �� / t �. AnPtication Accepted By— �" " ---- - - -- - ---- --- Date - ' x� -7 '.dditiona! Comments:--_-,�t - - --- ----- -- -- ---- -- / GIKIalse II Gro Inspection ase Final!ns ectlon -Date 3''3_z_',f/_---- Inspection:By � �-- Date 31 Inspection By_ -jh ?". ` PER - H ❑ January t 3 Reue�veC By January 31 ❑July 1 8 Received 3y July S' r BILLING _. -___—_—_.___. __.___. — —._.__ - ee Is Due: ❑ ANNU I LY PER UNIT ❑ SITE ❑ EACH REMIT r Ex PLA14ATION a REMITTANCE 5 AMOUNT DUE CHECKED D` DATE DATE REM TTED AMOUNT " EEE L_ �� - —�--� 0 -- -- — r: SS -- --- _._------ -- F NAL1V � ' 1. — —.— _.----_-.—_ ir OTHER I : T i DTHF A --A `1 i �--4 - - --1-c C --- - -- -- - - -- ------ ^.roe vetl by Date Rercc,pt No. P, 0 No Issuance Dale Mai'ed Delivered LAPPLICANT—F=.L'RN f.LL COPIES TO: ENVIRONMENTAL HEALTH PEAMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bat 2009 STOCKTON,CA 95201 c 11, 5, �y rte_ � �