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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 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 will or a Grout Inspection prior to grouting and a final inspection. Title:0.4-irt-N-4-'1 Date: raw Plot Plan on Reverse Side) r 4 FOR OFFICE USE: I APPLICATION (For Non-Transferable, Revocable, Suspendabie) ENVIRONMENTAL. HEALTH PERMIT , ...., COMPLETE IN TRIPLICATE) ...2_,e.e e C. /4 ,4_,,,, ..c. .c......; 4ATER QUALITY 2-0 —410 ---1- 0 4 Application is hereby made to the San Joaquin Local Health District fora Permit to construct and/or install the work herein described. This application is t made in compliance with sn Joaquin County Ordinance No. 1962 and the r les a d regu latioris oiNth&San JoaqqinkLocal lipalth Igistrict77_00 C-1,11Z i' 'N.t I Exact Site Address al • ftrzfriFi; ii 4ei. ..5"- 6V. , ceostyfor im -Pie d ON, _ C)C-- .) \ i Owner's Name A ifh,....dr_ P. P,,±4_, e-- Sao f"- Phone ,....t‘Ydz 5:— 0 22-0 i Address _ ..62fa_q__,.4 -4, - City Y,,.. ,,, ,..., ..., ......, ,., N. Contractor's Name _at (0.; q$-. j-_Or iltriv License #3?-0-5"9:,:. Business Phone liZ Y ....'00--/ 7 .7 .00— ICS Contractor's Address 3 0 a Cf_ at froy Emergency Phone ••.....1 . 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ' No TYPE OF WORK (CHECK): NEW WELLA DEEPEN 0 RECONDITION DESTRUCTION El WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION 0 PUMP REPAIR El REPLACEMENT!: DISTANCE TO NEAREST: Septic Tank — Sewer Lines ---- Pit Privy Sewage Disposal Filld Other Cesspool/Seepage Pit — Property Line)--0_1_ Priv-ate-D rOmestic Well "---- ' Public Domestic Well INTENDED USE TYPE OF WELL 1 i ( ,L=1 INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation ____6, • I i DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing & A A. El DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing /60 psr IRRIGATION g GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION Kr ROTARY Type of Grout Ow 0 DISPOSAL . i 0 OTHER Other Information P /qv b,-- -Pr:- 17bi±cfm, d 12 . t 1:1 GEOPHYSICAL Surface Seal Installed By: awn ei, PUMP INSTALLATION: Contractor _4 Type of Pump H.P, ---- PUMP REPLACEMENT: 0 State Work Done l.") PUMP REPAIR: ID State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure . .....- `i --t ifl Z._ k Signed X FORD ARTMENT SE ONLY Applications Will Be Processed When Submitted Properly Completed. Be sure TO sign me Appricamuli. PUMP & WELL 4 1 Date # PHASE I Application Accepted By Additional Comments. Phase II Grout Inspection Inspection131 neix.Da;e4 2-_1/ / 0 71, 413 Fee Is Due: •El ANNUALLY • • 1_1 PER UNIT 0 PER S BASE EXPLANATION El EAC • BILLING DATE REMITTANCE DATE Inspecton By anuary 1 & Rec REMITTED Phase III Final Inspection ate i 21G0 y January 31 0 Juiy 1 & Received By July 31 REMIT - AMOUNT DUE CHECKED AMOUNT FEE 14/J LESS PRORATION PLUS PENALTY OTHER OTHER - ) kp 9 — 5-7 9/IN 11 Issuance Date Mailed Delivered -- Received by Date I Receipt NO. • Permit No APPLICANT—RETURN ALI COPIES TO: ENVIRONMENTAL HEALTN PERMIT/SERVICES 1801 E. HAZELTON AVE.. P.O. Box-2 -TOCKT 0N, CA 95201