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Applications Will Be Processed When Submitted Properly Completed. Be gy'Cejo�5i4AWAr611ivatio�j FOR OFFICE USE: 1 I APPLICATION jL7 ` `—' ``' tt°° Ifs" (For Non-Transferable, Revocable, Suspendabl j t 7 � P&WELL ENVIRONMENTAL HEALTH PERMIT A.R (COMPLETE IN TRIPLICATE) WATER QUALITYSA1 1 r,( f_ I`y LOCAL 6rW`�. Application is hereby made to the San'Joaquin Local Health District for a permit to construct and/or install tl �ru�lrc6ei�[fesFF�bThis application is made in compliance with San Joaquin County Qjdinance No. 18f22-and the.rules a re ulations of the an J quin Lo I Health District. Exact Site Address CCity/Town c - , Owner's Name QN Phone Address Z,, I City Contractor's Na ► �-� NrBusiness Phone 7 '67 Contraclorp AY*ks,� Emergency Phone f Is Certificate of Workman's Compensation l,n,.s_uranncc on File With SJLHD? Yes No t TYPE OF WORK (CHECK): NEW WELL LT DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,, PUMP REPAIR❑ Off REPLACEMENT❑ 1l • DISTANCE TO NEAREST: Se tic Tank b Q Sewer Lines I P / �� Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line �a Private Domestic Well Public Domestic Well INTENDED USE III TYPE OF WELL n ❑ INDUSTRIAL I! ❑ CABLE TOOL Dia. of Well Excavation &,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C%, � ❑ IRRIGATION ' ❑ GRAVEL PACK Depth of Grout Seal ZT14 _ ❑ CATHODIC PROTECTION NARY Type of Grout ❑ DISPOSAL 1; ❑ OTHER Other Information I ❑ GEOPHYSICAL I Surface keal Installed By: PUMP INSTALLATION: i� Contractor _ f Type of Pump H.P. a PUMP REPLACEMENT: ji ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: I 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, anis 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 forwhich 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a G t Inspection pr' to grouting and a final inspection. Signed X Title: Date: �Z (Draw Plot Plan on Reverse Side) - 1 " FOR DEPARTMENT USE ONLY PHASE j p Application Accepted By Date ` 8— f Additional Comments: - Phase II Grout Inspections ' .,_--Phap III Final Inspection Inspection By N Date fll Inspection By [},ate / Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 39 ❑ July 1 &Received By July 31 REMIT BASE ,I EXPLANATfON BILLING REMITTANCE $ . i; DATE DATE REWTTED - AMOUNT DUE CHECKED _ AMOUNT FEE ;� 0 LESS PRORATION PLUS PENALTY jj OTHER io f-� OTHER 'I? l Received by Date i. Receipt No Permit No I Issuaned Dat .. Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .. ._--JL