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L - Applications Will Be Processed When Submitted Properly Completed. Be S 6,�rh�p0:ICA1ior.-L UJFOR OFFICE usE: APPLICATION t s (Fot Non-Transferable, Revocable, SuspendableRL ^ 9&WELL t` f f I ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY SAN •jOA�.1OUIN �"�'?O`��'^AL ! Application madeto theSan Joaquin Local Health District fora permit to construct and/or install th"F,46T-ern90l�ti+��'`I`hisapplication is Ap Y made in compliance w th Sa Joaquin County Ordi ance No. 1862 and the rules and regulations of the SnOJgiquin Local Health District. i Exact Site Address 4639 Live Oa R�� City/Town!!1L, ,CC,LL / j Owner's Name Phone 1.w "r`"' W; AddressCity Lodi k462-1424 Contractor's Name lWar_ha-Ho, T3t— License#17704.0 _ Business Phone Contractor's Address -2 247 N j2 nk• T on e Rd . _ Emergency Phone — Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes x _— No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 . 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 Property Lihe Private Domestic Well Public Domestic.Well INTENDED USE Y TYPE OF WELL ❑ INDUSTRIAL. ❑ CABLE TOOL Dia- of Well Excavation i ® DOMESTIC/PRIVATE 11:1 DRILLED Dia- of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION {'0 ROTARY Type of Grout I ❑ DISPOSAL �0 OTHER Other Information k El GEOPHYSICAL 11 Surface Seal Installed By: 6 PUMP INSTALLATION: Contractor Type of Pump H.P. r PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: W State Work Done Pump repair repa-1x--w1xe— DESTRUCTION OF WELL: !Well Diameter Approximate Depth Describe Material and Procedure 1 41 w 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. ° Home owner 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." F. Contractor's hiring or sub-contracting signature certifies the following."I certify that in the performance of the work for which this permit is issued, I shall employ persons be o workman's compensation laws of California." I call r a Gro n e n prior gro tin and a final inspection. ; V. ZPr es . Date: 6-15-80 Signed Title: 1 (prow Plot Plan on Reverse Side) j FOR DEPARTMENT USE ONLY i PHASE I — Date 7 Application Accepted Bye. Additional Comments: Phase 11Grout Inspection P s III Fin section / Inspection By Date A/4. . Inspection By Date �!`� � x Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS I PENALTY OTHER OTHER Received by - Date Receipt No Permit No. Issuance bate Mailetl Delivered r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 JJJ