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FOR OFFICE USE: APPLICATION =orNon-Transferabller'Revocable, Suspendablir i3 ' YENVIRONMENTAL HEALTHI PERMIT~ (COMPLETE IN TRIPLICATE) ~ WATER QJALITT Application is hereby matte to the San Joaquiolocal Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin4ounty4rdtnance No. 1862 and the rules and regulations of the San Joaquin Local,Health.District. Exact Site Address McMo w Lary,L)A2rV- M,5nn Riri V4 VY-6. SDcity/Town TY rtprN Qd. e . 51. - ...--- -- Owner's Name i.>rr'i -ReSn Aeras;ori J I -'hone g3S-,1-_'A 4 Address I I I q Adam • .city - Contractor's Name Pm.r-)I n Bros. Y . Tlvr License#-ZQQS13 Business Phone,- Contractor's hone,Contractor's Address-.;;,5i2zs_ .IArylaje. Ave++, Milos:< Emergency Phone -4,5- Is Certificate of WorKmarrs=Compensation Insurance on File With SJLHD? Yes -- No _- TYPE OF WORK (CHECK):`1,NEW WELLI' DEEPEN ❑ RECONDITIONE3 -DESTRUCTION❑ -- ---WELL CHLORINATION ❑ WELL ABANDONMENT❑:-.-OTHER ❑ "PUMP•INSTALLATION ❑- PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank IAD N Sewer Lines Pit Privy Sewage.Disposal Field Cesspool/Seepage Pit Other -'Property'CiNe Private Domestic WeII /�2 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 0-CABLE TOOL Dia. of Well Excavation // e G1-DOMESTIC/PRIVATE 93.DRILLED_.....,T - Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN ' . Gauge of Casing / [JJ .❑ IRRIGATION MIGRAVEL PACK -Depth of Grout Seal �a. ,�-- -E CATHODIC PROTECTION 91-IROTARY =„Type of Grout--------- 43 DISPOSAL ❑ DISPOSAL ❑ OTHER Other Information1hh �!� -�- t ❑ GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: Contractor _ - - Type of Pump H.P._- PUMP REPLACEMENT: ❑ State Work Done - - PUMP REPAIR: ❑ State Work Done - d DESTRUCTION OF WELL: Well Diameter Approximate Depth —; - Describe Material and Procedure r 1 herebyleertitythat I have prepared-this applicaflom and.that-the work will be done..,in%accordance with Finn Joaquin County k ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - Homeowner or licensed agent's signature certifies the following:"I certify that intheperformanceof the work for which this permit.. is issued;-I shall not employ any person in such manner as to become subject+toworkman$compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work 1prwhich this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." c Ivwiil�l scall formGroutt Inspection prior r to grouting and a final inspection. ''7� + Signed X _e/ r-r-n 1�, 1, !Q.l.l 1L A<LA.V1 / Title: V�� Dale, r7 _ � (Draw Plot Plan on Reverse Side) C FO DEPART ENT USE ONLY PHASE I /I - Application Accepted By oy -..- Date J Additional Comments: - Phase 11 Grout Inspection / _, � P 111 Final Inspection- . --Inspection By s mate ' inspection By �• Date y� C;� Fee IS Del:❑ ANNUALFJr" ❑ PER UNIT ❑ PER SI ❑ H ❑ Jan ry 1 6 Recaive0 By January 71 0 July 1 d Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ ' AMOUNT DUE -CHECKED TE DATE REMITTED �j AMOUNT FEELESS 7S 7 a PRORATION PLUS PENALTY — OTHER OTHER 29- 8Y9 7-a6-99 Received by -Date Receipl No. Permit No. issuance Data - ' -Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVA P.O.Boa 2009- STOCKTON.CA a^1