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FOR OFF,,ICE USE: APPLICATION li• �or Non-Transferable,Revocable,Sus p a c-.7 V Alf WELL ENVIRONMENTAL HEALTH PE NOV I 9 1980 (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permitto construct and/of3r llttlaktp�R•I)h jet destic�bed.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations� gsw��l1q. I` i-Pbalth Dis is Exact Site Address 17M11'3 E, 1 C>C-1'rs R0City/Town J Owner's Name LJ.S• GQ5,- k4ol. T&L. Phone IF lout I Address'? •O. 17. (zmuiau N City 1.G+GK1=F<220 (Z�b Contractor's Name 11dIEF1}R1tlit� POMP License#CLC 3 t Business Phone-127-55*48 O Contractor's Address IR[Z-Ry�x 113. I IX&epngo Emergency Phone t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ^-) WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ 2 PLXJr»P5_ 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC - 0 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ 'ROTARY Type of Grout 11DISPOSAL :11OT4ER`. Other Information ❑ GEOPHYSICAL - - Surface Seal Installed By: PUMP INSTALLATION: Contractor ype of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done RL'TIP#I— I5Frrlurbtne.—YIP(�1S +LID QX�'P11SIm PUMP REPAIR: ❑ State Work Done Rte#2-3�hr�T. — 11P.LL1 C]otvlS 'F 20 �'. PkS�pL')� DESTRUCTION OF WELL: Well Diameter Approximate 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.' Home owner or licensed agent's signature certifies the following:"I certify that in theperformance 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 of California." (� Contractor's hiring or sub-contracting signature certifies the following:"I certity that in the performance of the work forwhich this permit is , I shall employ persons subject to workman's compensation laws of California." I w l a G t Inspection prior to grouting and a final Inspect' It Signed X Title: /n19L/./'� _ Date: IJ (Draw Plot Plan on R verse e) FOR DEPARTMENT USE ONLY PHAyl • V1_Applation Accepted By l , " DAJ ko Additional Comments: d Phase 11 Grout Inspection Ph a YPinal I�rnnsl��ae°°ction z Sc) Inspection By 1r, Date Inspection By Date a Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 h Received By January 31 //❑ July 1 8 Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED ` AMOUNT FEE 0 LESS PRORATION PLUS PENALTY OTHER OTHER os SS 1�1 Received by Date Receipt No. Permit No. sauance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.Boa 2111119 STOCKTON,CA VS201