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- -- _ Appticntions WI."Be Prpcesstd When ;ubatNted Properly Completed.Be Sure To Sign The Application. SPR OFFICE USE: _j APPLICATION READY FOR INSPECTION .NOW ` iFor Non-Transfera'.fe,Revocable,Suspendabie) - PUTAP&W.ELL ENVIRONMEN -AL. HEALTH PERMIT (COf11PLETH tT!TRIPLICATE) - 'VP ER QUALITY Application tr."wbyrnw.letotheSer.JoaquinLacs!Health:.istrict'-I ermi;toconstruct androrinstall the work herein descrihed.Thls6pptication is m;tde in cornp'i.lncc with San Joaquin County Vrdl-idnce No. 1832 .Li rules anG regJlations of the San Joaquin Local Health Distria . Exact Site Address Z 1100 E. Li Bert Rd. x Y.. _.-- _ _., ._ .__ city/Town Galt ' Y ._w Phone 1 ( L?wrer's Name FIO !?S Dd1T � � nedrhs<._l._1ZOQ_E..._Liberty Rd.---•-----------•--------._—��.. C;ty--Galt __ . t -- CaniraCtors Name .C`iOQ)7Z]nq-PLZm�]�_ License s09 __ Business Phone -554S-r: +' Contractors Address 17754 N. H_wy $8,__LOCk@Ordr mergency Phone - Y y Is Certiticale of Worxmsn's Compensation Insurance on Fiie With SJLHD? Yes ,.-� No. TYPE OF WORK(CHECKI: NEW WELL❑ L)EEPEN❑ RECONDITION❑ DESTRUCTION17 �? WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ Ptl'Jp INSTALLATION❑ PUMP REPAtRIX C :REPLACEMENT DISTANCE TO NEAREST: Septic Tank Sewrr Lincs-.._., .-... .. _ .Pit Privy Sewage l}isposal Field—_ � Cessrool/Seepage Pit _ Other- Property lher_Property Line Private Domestic Well Public Domestic Well 'au. INTENDED USE TYPE OF WELL - - ii "❑ INDUSTRIAL - ❑ CABLE TOOL - - Dia.of Well I f Excavation- OE5iGIDRILLED Dia.of Well Casing ice / DOMESTICIPUBOC 1:1 DRIVEN Gauge of Casing ❑ IRR1+3A"1 1pN ❑ GRAVEL PACK Depth et L+'OuT Seat.- 11 eat.—❑ CATHODIC PROTECTION ❑ ROTARY Tgpe of Grot I :• ❑ DISPOSAL ❑ OTHER Other Information ❑ afOPHYSICAL - Surface Seat Installed By: PUMP INSTALLATION Contractor #: --- - -- -- --- y ri Type of Pump ? PUMP REPLACEMENT- ❑ State Work Done i PUMP REPAIR: . State work Dane Ghana- rOT[t_ AHPoHP -� �' '•" DESTRUCTION OF WELL: Well Diameter �— _. Approximate Depth_ Describe Materia$and PrOCOdure i hereby" ertEfy that l have prepared this application and that the work will be done4 accordance with.Saa Joao„in CounTy r ordirances.state laws,and rules and regulations of the San Joaquin Local Health rict, _ Homeowner or licensed agent's signature ceril lies the following:1 certify that in the performance ui the work iorwhich this perm1 is issued, l shah not employ any person in such manner as tr become subjeCt'to'workman's compensation laws of California Contractors hiring or s -contracting si nalure certiffes the following. I certify that in the performance of the work,fbrwhich this a' g 9 9 4:., y p permit i ' sed.!s 1 mploy persons subject to Workman's compensation laws of California." y I will r a Gr spe ion prior to grouting and a final Inspection. + Signed X _ v._- _ _. __ -___- - -- TIME:.----Bkpt•_-. Date L39� Q/83 I (Draw Plot plan on Reverse Side) FOR DEPARTMENT USE ONLY i PHASE t Application Accepted By—h.- '�4i.(/!----- -._ - _�__-_-_- _ Dale Additional Comments:-�—�---------.------ ----- - -- - Phase II Gr ut n ection hdse !Final Ins eeti*ii JQ� 4 Insper:tion By-- Ve -- - P"ction 8y --- --'ins r te_ �f Fee is Dne:O AWPLIAttr -p PER UNIT^�©PER SIT[ ❑EACH _ ❑ January I b Ra-,iced er'Janelary 3T'-' .•i�July-r 6 n•tlMed"6Y July 31" „- _ REMIT't" SASE - I 7XPLANATION } BILLING - I FEMI:TAHCE I S AMOUNTPIJE.;: CHECKED GATE _ DATE `- i REM177E6 AMOUNT . r' FE£' -- '4 ---i --_-- I — sem - -I - - LESS PRORATION — 1� —.—_— i.�m_..._.._w Ptus 3' PENALTY I i _ c7HER x ' fff OTHER Pr card- C''- pecnPI to F•Err..ot HU. ssuar_e'Date R4'.;u peirv.red ]1 APPLICANT-IMRIf ALL COPIES TO £HYIRorIMETlTAL HEALTH P'_F,.•r SERVICES 1601 E.NAZFLTON AVE,P.O.'Bei 7JOf STOCKTON,CA SSMr i