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Applications Will Be Processed When Submitted Properly Completed. Be Sure iYA St�h cT11A)App�icaN'eti.I I I' FOR OFFICE USE: APPLICATION ) a(For Non•Transferable, Revocable,Suspenda14A 0 ILUOMVELL ENVIRONMENTAL HEALTH PERMIT ( 0S-[0o, / F - N. -. ..�....- .. ' W T QUALITY SAN Ip;QUN LUC U (COMPLETE IN TRIPLICATE), Z2: M.LL.✓-�-h^/ ,Qx.,Q , ,t. nl�)��!(`T Application is hereby madeto the San Joaquin Local Health Distric forapermltto construct and/or install WA1*ThJel tr tl cn a This application is made in compliance with San Joaquip C unty Ordinance No. 6 �n the-r�ul•esr uIa ' ns of the San Jpaquin L-o/al Health District. O Exact Site Address /J City/Town F-/ I9 'P 0 Owner's Name { 0 IW.4.-Aaav> Ir..c1.c i!:. It,, Phone D Address City - } K d 0 Contractor's Name e License# 3 7 0 U(Business Phone Contractor's Address 0 litle .1 Emergency Phone ";a yn p Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L� No TYPE OF WORk (CHECK): NEW WELL IK DEEPEN ❑ RECONDITION❑ - DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ C( REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Figld Cesspool/Seepage Pit Other Property Line a Private Domestic Well Public Domestic Well "1 INTENDED USE TYPE OF WELL •5 !� I ❑r�INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Die. 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 Surface Seal Installed By: _� �K PUMP INSTALLATION: Contractor�� `i') GL�^ S � [ vL L_ Type of Pump ' H P J s PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done a ' DESTRUCTION OF WELL: Well Diameter Approximate Depth c - Describe Materiel and Procedure 1 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 agerM'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 of California." Contractor's hiring or sub-contracting 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." ( I�1{IILaW or a Grout Inspection prior to grouti and a al Inspection. I Signed X. itle: Data. /99— 13 . (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY0-71,r PHASE I , r� Ut,�(1�(\, �Q W� Dale p Application Accepted By "'hhhaaa 444�'t® 1 1tJ1/. 6— Additional Comments: ... _ Phase 11 Grout Inspection Phase 111 Final Inspection Inspection By �1�""'— Date��/r% Inspection By" •� r+d� Date �/ - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Recelded By July 31 REMIT BASE KXPLAN BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE e REMITTED AMOUNTFEE / � ..LESS � .GVYr. KPRORATION PLUSPENALTY OTHEROTHER (olglxi n..-.:..w,... n..: ��anc.ine Nn - Permit No. lbw lncee Mailed Delivered