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Applications Will Be Processed When Submitted`P,roperly Co r ` auk0rnign The A �Ion.�*''ORI FICE USE: APPLI TIO`1 Non-TransfePable, Revocable, ndabl>pR15198 02- (For ; 4ENVIRONMENTAL HEALTH PERMIT 0 �0_ ,�LPLIMP& I� t�t {COMPLETE IN TRIPLIICATE) WATER QUALITY SAN. 30 'Q U� R1�T Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct and/JAEA l�lie work.,herein described.This application is 4. made in compliance with San Joaquin C unty Q�dillance/No. 1862 and the r les and regulations of the San Joa uin Local Health District. Exact Site Address IL i J g1 �4 ��ac City/Town _Age Z� , Owner's Name _ Phone " Address �` City Contractor's Name k 1•' S , - 3 License 44"e,l� Business Phone_ -r Contractor's Address Emergency Phone 1 Is Certificate of Workman's Compensation Insur nce-on File With,SJLHD? Yes fr No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN J -�. RECONDITION ElDESTRUCTION❑ WELL CHLORINATION 13 WELL ABANDONMENT � _ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR i, REPLACEMENT❑ I � F_ + DISTANCE TO NEAREST: Septic Tank /.rz,Sewer_Lines -L 4� fit Privy Sewage Dispo l Field Cessp of/Seepage Pitr - Property Line _ Private Domestic Well , _Public INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing _ s�e?f�j ❑ DOMESTIC/PUBLIC ❑ DRIVEN- ,,,Gauge of Casing IRRIGATION I� El GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION - ❑ ROTARY Type of Grout O ElDISPOSAL E] OTHER Other Information ❑ GEOPHYSICAL urface..Seal-Installed-By:_ PUMP INSTALLATION: Contractor. J'`d 5•- - �./ -- i� Type of Pump 7�_ rh,!22 e, H.P. © 4 PUMP REPLACEMENT: ❑ State Work Done ! PUMP REPAIR: 11, ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure a I hereby certify that I have.prepared this application and that the work will be-done-in accordance with San Joaquin County ordinances Mstate laws, and rules and regulations of the San Joaquin Local Health Distract' Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for.which this permit j is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." r 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 wi all fo a Grout Inspection prior to grouting and a final inspection., - Signed X 'd `�---- Title: J Date: Plot Plan on Rever's'e Side} R DEPARTMENT USE ONLY ) : I PHASE'`I i ApplicAtion Accted By Date, ep ,- Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection p Inspection By tt. 2 Z1nsp`etio,,EB. rQ hxb�u Date l rtr Fee Is Due: ❑ ANNUALLY [I PER UNIT La PER.SITE ❑ EACH ❑ January t &Received By January 31 ❑ July I &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED D TE DATE REMITTED AMOUNT t i FEE t „LESS PRORATION _ PLUSl , PENALTY f y v OTHER OTHER Received by 1[. Date Receipt No, Permit No. Issuance Date r+VVJY Mailed Delivered - r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,Cp 95201 !