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Applications Will Be Processed When Sud riltted�Properly Completed. Be Sure To Sian The Application. _ _NR FF CE USE: A►PP01CATION (For Non-Transferable, Revocable,Suspendable) f E1, lUAP.&WIELD ENVIRONMENTAL HEALTH PERMITg. l 'r,� -- WATER QUALITY (COMPLETE IN TRIPLICATE) Irks Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 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 S CC 14 Tr�il:[iLQ 1"Ai) ..1 Ili C'4.)7" '), Z �� _ City/Town 2 ('. �- �/tru C�j_ 53 3-_ 5; Owner's Name Phone Address _ City Contractor's Name ..� License fl Business Phone Contractor's Address i`�,CK i�.yr W Aft:��*L� Emergency Phone t - 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❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field %Cesspool/Seepage Pit Other I Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL j r. i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ ! ❑ DOMESTIC/PRIVATE 12`DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing ❑ IRRIGATION ❑RAVEL PACK Depth of Grout Seal L " I `�� 13CATHODIC PROTECTION ROTARY Type of Grout _ ` ❑ DISPOSAL ❑ OTHER Other Information 7T� �� '• GEOPHYSICAL S>r1r �Sg l Inst lle tom` PUMP INSTALLATION: )Do'no — Type of Pump ___ H.P.. PUMP REPLACEMENT: ❑ State Work Done i PUMP REPAIR: © State Work Done DESTRUCTION OF WELL: We11 Diameter _ _.. Approximate Depth Describe Material and Procedure .1, i , —T,t c' f rr�3�.�t�I,a I:✓rS t= /{<?L.CS i t_l., 77 c) ��._ St l 1 --l�t S1l1:tL r ( PrriLi _l'3 ',ei1lfA�d c`h_ a '15��i�a�fj 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 D€strict. &Z Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this rmit �'{ 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." y I w I call for a Grout In pection pr r to grouting and a final Insp ctlon. / J q1 r Signed X _ t t— J� �r-�� Tille: _ i yup C��S- __— Date: l C mossy�. (Draw Plot Plan on Reverse Side) U FOR DEPARTMENT USE ONLY PHASEI C Application Accepted By `�' _ Date l �'d F Additional Comments: Phase 11 1 inspection I Phase III Final Inspection inspection 8 Date • Inspection By Date i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_ ❑ PER SITE ❑ EACH ❑ January t d Rec6ynd By January 31 Cl Juiy 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT 1 FEE 4 #4/ 3 f LESS PRORATION PLUS PENALTY OTHER OTHER <5 3 d 3 4� Received by Date Receipt No. Permit No. Issua ce Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 9520t