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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheApplication. FO. OFFICE USE: APPLICATION. (For Non-Transferable, Revocable,Suspendable) U P E— ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY ~„ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is made n compliance with S/an Joaquin County Ordina ce N . 1862 and the rul and gulat ns of the San J quin Local Health District. Exact Site Address 4 l +� d rim ° Ity/Towns O Owner's Name � 0 n'' ; �� ►'� ' Phone Address 1. City Contractor's Name !✓ o�Jab0 Gtr License# 3 VgBusiness Phdne Contractor's Address k, ff�meq n Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Vol No TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION l PUMP REPAIR REPLACEMENT D DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I, Sewage Disposal Field Cesspool/Seepage Pit ,Other Property Line -... Private Domestic Well Public Domestic.Ws<ll INTENDED USE - .1 TYPE OF WELL ; pj T ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑�,�DOMESTIC/PRIVATE ElDRILLED Dia, of Well Casing b UerDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 11 ,L.IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ENVI OI��'I E N T R.E t 7 �j 1:1 CATHODIC PROTECTION ❑ ROTARY Type of Grout 1n p # ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL, Surface Seal Installed By: PUMP INSTALLATION: Contractor G Type of Pump 5'- A AA42 H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done r DESTRUCTION OF WELL: Well Diameter a Approximate Depth Describe Material and`P�rocedure I hereby certify that I have prepared this applicatign and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations'0Aa San Joaquin Local Health District. �l 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 asitia-become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that ir,i the performance of the work for which this i permit is issued, I shall employpersonssubject to workman's compensation laws of California." I wii all f r a Gro13t Ins pe 'on p ' r to grouting and a final inspection. ) p Signed X I I�_ " - _ Title: _ / Date: !D (Draw Plot Plan on Reverse Sade) # FORD PARTMENT USE ONLY ' PRASE 1 /i! Application Accepted By Date Additional Comments: 1 Phase 11 Grout Inspection Fin pection Inspectioni By Date Inspection B Date S [ �� Fee IS Due: 11ANNUALLY Q PER UNIT ❑ PER SITE `` ]•EACH ❑ January 1 &Received By January 31 El 1 &Received By July 81 REMIT ` BILLING 'REMITTANCE $ �{ BASE } EXPLANATION AMOUNT DUE CHECKED { DATE DATE REMITTED AMOUNT ------------------- i ' I FEE i a C3 LESS PRORATION PLUS y { PENALTY OTHER OTHER r' I t ' f Received by i Date Receipt No. Permit No. - Issuance Date Mailed Delivered Box 20U9 STOCK70N,CA 95201 APPLICANT'RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH.PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.