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FOR DEPARTMENT USE ONLY <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. — <br />APPLICATION <br />(For Non-Transferable, Revocable, Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />WATER QUALITY <br />FOR OFFICE USE: <br />Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is <br />County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br />City/Town -Tie y <br />Address 7 1 7 /V, a ft_ giht.7" <br />Contractors Name __H F---,IgNiff&r.__ 8, er3 i...ve t <br />Contractor's AddrescASP.,,Ntl/),Cg Emergency Phone <br />Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes J., No <br />, Other . <br />A • <br />INTENDED USE <br />Nr DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing ‘ I' <br />0 DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing /C_O PS/. <br />IRRIGATION AGRAVEL PACK Depth of Grout Seal ert) I • J <br />CATHODIC PROTECTION lia ROTARY Type of Grout CI F.: in <br />DISPOSAL 0 OTHER Other Information <br />GEOPHYSICAL Surface Seal Installed By: <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />PUMP REPLACEMENT: 0 State Work Done <br />PUMP REPAIR: Sfalc-Wbrk—Don-e- ....- <br />DESTRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure • <br /> <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 />Home owner or licensed agent's signature certifies the tollowing: "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 />permit is issued, I shall employ persons 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 for which this <br />Signed X I will call for a ut Inspection prl lo grouting and a final inipeestio <br />Date:( , Title: <br />(Draw Plot Plan on Reverse Side) <br />COMPLETE IN TRIPLICATE) <br />made in compliance with San Joaquin <br />Exact Site Address 7.1 CV 61etaNT LAI fff .0 , <br />Owner's Name S i tiet VSZ OS 0/4 i /2.Vr <br />Jet), <br />License # 079%00 <br />Phone <br />City <br />Business Phone <br />TYPE OF WORK (CHECK): <br />WELL CHLORINATION 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST! <br />0 INDUSTRIAL Dia. of Well Excavation <br />:iSewage DI;posal Field -Cesspool/Seepage Pit <br />Property Line Private Domestic Well Public Domestic Well <br />TYPE OF WELL <br />0 CABLE TOOL-.-" <br />*a <br />NEW WELL DEEPEN 0 RECONDITION 0 DESTRUCTION 0 <br />WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION 0 <br />/ <br /> <br />,Septic Tank Sewer Lines - Pit Privy <br />PUMP REPAIR 0 <br />" c'T <br />CS) <br />IMF <br />k Appzoximate Depth <br />PHASE I <br />Application Accepted By <br />Additional Comments: <br />Inspection By <br />Fee Is Due: C3 AN ,ALLY <br />FEE <br />LESS <br />PRORAPON <br />--- <br />PENALTY <br />OTHER <br />OTHER <br />BASE <br /> 07 Date <br /> tiA4 EA H <br />EXPLAN <br /> <br />Janti'ar a el e,ved By Jan a \ ,taJLily 1 & Receivea By J.Jly 31 <br />iftrJT DUE C:iirAil<TED <br />fiLt Val //.44 <br />AMOUNT <br /> <br />_ -14,0) edidirote <br /> <br />0.141.4*L1- 34.lef‘l - <br />i Grout Inspection Phase III Final Inspection <br />Date Inspection By Date <br />1.1 et -r8 Se.1 1, 39c <br />Receipt No Permit No <br />' APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />5- <br />Issuance Date Mailed Delivered <br />1601 E. HA7_ELTON AVE.. P.O. 8oie 2009 STOCKTON, CA 95201 Received by by