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FOR OFFICE USE: APPLICAT I�: (� � IJ'j It V �..%r Non-Transferable,Revo Suspendable)� —4P&WELL ENVIRONMENTAL HE PRIN112 j 1981 (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to consGAf dn&a'r'ili Ql Ne W k 1T11�rein described.This application is made in compliance thaS J3oaquin CountyOrdinanQa No.1862 and the rules and rddljlatlbA"f�elarfl 6aquin Local Health District. Exact Site Address // pD 7j I \L4c..f, "�'TCJ��FIm.,�'� City/Town Owner's Name 1'H a.�f�.� O'o^d C.vly A.lxC•-+� Phone 3 54/ 2.L Address �1 r:o 4 --ls�rn City .[ Contractor's Name License#A-� Business Phone Contractor's Address L2 - f.'.Q.. Emergency Phone6f,^4G 1 �^ Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRf REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Dorriestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ 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 ❑ GEOPHYSICAL J? Q Surface Seal By: PUMP INSTALLATION: _ Contractor Type of Pump H.P. PUMP REPLACEMENT: 0�State Work Done i PUMP REPAIR: J State Work Done DESTRUCTION OF WELL: -- - Well Diameter - -- - _ Approkim a Depth 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. Homeowner or licensed agent's signature certifies the following:"I certifythat in the performance of the work for which this peUJ permit J is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 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." r 1 r arpectilon prlor t grouting and a'fnal inspe4 on. L_- Signed Xi e: Date: _ (Draw Plot!#Ian on Reverse$Ae) I&. DEPARTMENT USE ONLY PHASE I �ny/�p� r}�q Application Accepted By _ �, Date v �, Additional Comments: Phqpq II Grout Inspectiona III Final Inspection Inspection By Date I Inspection By Date 1 l48' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE :❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DAZE DATE REMITTED AMOUNT DUE CHECKED FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. InVance Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 19111 E.HAZELTON AVE.,P.O.Bo[2009 STOCKTON,CA 9S101