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a' - ' Applications Will Be Processed When Submitted Properll omp'leted. 6B.SCire� o$ign fi�'Applicaiion. FOR OFFICE USE: APPLICA 2 (For Non-Transferable, RevoWl�,Suspendable),r, MP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) 25oS u1. /J c a�ER QUALITI �`;jf '�y51 ? r;? CAL, A .�� : 0�2—Z7D rD � Application is hereby made to the San Joaquin Local Health District for a permit toconstfgffil,i5d7olin lkt e u6r herein�described.This application is made in compliance with San Joaquin.County Ordinance No. 1862 and the.rules and regulations of the San Joaquin Local Health District. Exact Site Address N y... � _ City/Town __ is�+�.��✓ Owner's Name 't �� Phone t Address Contractor's Name " '-J License# fC.X 37_3j Business Phone'l- �2 S, Contractor's Address o• S Emergency Phonesf"' 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 O REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other T 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 ❑ OMESTIC/PUBLIC ❑ DRIVEN + I� IRRIGATION ❑ GRAVEL PACKDepth of Grout Seal CATHODIC PROTECTION 1:1 ROTARY 611 F Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL - .` Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT:- ❑ State Work Done I PUMP REPAIR: r State Work Done - DESTRUCTION OF WELL: Well Diameter Approximate Depth - i 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 p ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. tv1 Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit I 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." • I will call for a Grout Inspection prior to grouting and a final inspection. Signed X J?A� ./ �� -?"A e_ Title: As Date: T + (Draw Plot Plan on Revere Si e)' FOR DEPARTMENT USE ONLY PHASE i Application Accepted By �9/LQd`� Date Additional Comments: Phase II G out Inspection /gyp 111 Final spection y L Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY C1,PER UNIT ❑ PER SITE ❑ EACH - El January 1 &Rec d By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION- DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS a PHO RATtON - '•- ° - - ? PLUS - PENALTY OTHER OTHER 6. l._ Received by Date - Receipt No.' Permit No. •Is uance ate Mailed - -Delivered - "�- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 %�'.