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Applications Will Be Processed When Submitted Properly CompI4160B"uie To Sign The Appll n. FOR OFFICE USE: � 30 � ^J. '`{'� 1 ,-APPLICATIONS 16 1981 (For Non-Transferable, Revocable, 5uspendabl I UMP&WELL ENVIRONMENTAL HEALTH PE I,� yI-),r,4;j„}� J.0Ck �5f'S / WAT R EI Y �j . r� t TH D!STR9CT 2 b M C� /t��¢_ t (COMPLETE IN TRIPLICATE) On/ �� r� � �,,� ,Ery I �`'/ Application is hereby made tot San Joaquin Local Hellth District'fof etrt�iiTfo construct', d%or install the work.herein described.This application is made in compliance with an Joaquin County Or inance No. 1862 and rules nd regulations of the San Joaquin Local Health District. Exact Site Address � AA's `AP-4,- h *”, Cit /Town ` _ Owner's Name ea , i NG3 eq �: f1 � hoh� y�tfC -( 2 Address 'A AJ Lt-,-Q- � G City f LL 1 at-' Contractor's Name A- ___-1*1 0%4 License# 1 3��gsiness Phone 7 V `4 ) j Contractor's Address ' ) P V- 64 Emergency Phone 0 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes a.�r No TYPE OF WORK (CHECK): NEW WELL�]EEPEN ❑ RECONDITION E-1 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank / J Sewer Lines - � Pit Privy Sewage Disposal.Field _ _-Cesspool/Seepage Pit. _.._ __Other Property Line Z dli'1Private Domestic Well Public Domestic Well f INTENDED USE TYPE OF WELL r ❑ INDUSTRIAL _ ElCABLE TOOL Dia. of Well Excavation ! at , ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing "' '� ��ESTIC/PUBLIC ❑-DRIVEN Gauge of Cas ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Q-MnTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICALSu face Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT. r 1 State Work Done PUMP REPAIR: State Work Donei DESTRUCTION OF WELL: -Well Diameter Approximate Depth ) VDescribe Material and Procedure IV I thereby 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. I Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit 1 € "E is issued,-I shall not employ any person in such manner as to become subject to workman's,compensation taws of California." y 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." 1 will call for a o Inspection`prior to grouting and,a final inspection.IfN ' Signed X Ca - z ` i N' Title: Dat } (Draw Plot Plan on Reverse Side) FO DEPA TM ENT USE ONLY - PHASE I /) �� Application Accepted By c� Dat Additional Comments: - Phase Il Grout nspection l se I11 Final Inspection 167W J Inspection By � Date � � Inspection By Date I Fee Is Due: ❑ ANNUALLy ❑ PERUNIT PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 A- BILLING REMITTANCE $ REMIT d - BASE EXPLANATION AMOUNT DUE CHECKED DATE ,: ::�-, DATE REMITTED AMOUNT f r � EEE LESS fff PRORATION _ PLUS r ' PENALTY OTHER � j 1 [ OTHER ,� y6 Received by Date Receipt No. Permit No — -�f Issulance Date - Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201