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h cations Will Be ProcessedJ4JJ, Submitted Properly Completed. u i�iwn The Appli stion. FOR OFFICE USE: 1)EC 2 c) 19$2 APPLICATION0 I k.V F� (For Non-Transferable, Revocable, Suspend 4Oat,-WELL SAN JOAQUIN I_.CM11RONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATOEALTH DISTRICT WATER QUALITY Appiication is hereby made to the San Joaqui n Local Health District fora permit to construct and/or install tWrR herein described.This application is made in compliance with San Joaquin County Ordinance No. 1852 afnd/the rules and regulations of the San Joaquin Local H Ith District. Exact Site Address Q City/Town ,may, Yod Owner's Name ,C-1) / i( !.! Phone u 7 37 �,57 Address a ! /Ig )o _ City /1l Contractor's Name �`� Li rise#.� J 7��Business Phone Contractor's Address l`� !/ 0 �J� Emergency Phn Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No W TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ �I REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 'k Sewage Disposal Field Cesspooi/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing j ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout a ❑ DISPOSAL ❑ OTHEROther Information ElGEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor -S Type of Pump ,8 H.P.] I PUMP REPLACEMENT: Pa State Work Done14" J!-/q PUMP REPAIR: ❑ State Work Done 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. l Homeowner 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will c ora rout Insp ction prior toZrting and a Lina! inspection. ) Signed X r,. Title: - /Yle 2 -_ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By 12 31- ;9'1Date Additional Comments: Ph se Grout Inspection se f Final Inspection Inspection By Date Inspection�By SJ I Date �^ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEES OO LESS PRORATION PLUS PENALTY OTHER OTHER y S 3 t7� Vty g l Received by Date Receipt No Permit No. Issuance Dale Mailed De_livered -APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �!