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2 Applications Will Be Processed When Submitted Properly Completed. Be SInSignThe Application. <br /> FOR OFFICE USE: APPLICATION AUG 23 1979 <br /> (For Non-Transferable, Revocable,Suspendable) f ELL <br />= r ENVIRONMENTAL HEALTH PERMIT SAN J0AQU1RuVA6l,_ <br /> HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework,herein described.This application is t <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the_ru-le and regulations of the San,aJooaquin Local ealth District. - <br /> Exact Site Address .4.3 Zo k— 1 / �1 ,/���. City/Town G-�7 A4c"1/L✓ <br /> Owner's NameA..'AZ� CJ JW Phone 613 <br /> C7 <br /> Address City _ 1 <br /> Contractor's Name License# 02 Busine Phone `w7 <br /> Contractor's Address ,i9?Wl A.) t{�� _ Emergency Phon �y^ <br /> i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �I <br /> TYPE OF WORK (CHECK): NEW WELL El' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � <br /> - WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTA ATIO � PUMP REP R❑ <br /> REPLACEMENT 13 &.-0 Juzau � be rg��d�� 044 � � �2tea.,c-6 6Ey ��c1n1L�i� <br /> DISTANCE TO NEAREST: Septic Tank Sewer-Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ` <br /> Property Line Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation d <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ][�I <br /> ❑ GEOPHYSICAL P SuVace Seal Installed By: i <br /> PUMP INSTALLATION: Contractor 7'49' 62Ci � G _- <br /> Type of Pump 4-. H.P. / tc <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' all for a Gro t Insp tion prior to grouting and a final inspection. j <br /> Signed X Title: � AJ Date: e©�/"-79 <br /> (Draw Plot Plan on Reverse Side) t <br /> r f <br /> i F RD ARTME T USE ONLY <br /> PHASE 1 7 <br /> Application Accepted By Date <br /> Additional Comments: " <br /> Phase II Grout Inspection Pha Final 1 coon <br /> 4 5� �y <br /> Inspection By Date_ Inspection By ate <br /> 4Fee Is Due: ❑ ANNUALLY . ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE- EXPLANATION DATE DATE- REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS 1 <br /> PENALTY t <br /> OTHER <br /> i <br /> (NER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTDN AVE;,P.O.Box 2009 STOCKTON,CA 95201 <br />