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Applications Will Be Processed When Submitted Properly Completed. Be Sure T n ly 5a n.V JI FOR OFFICE USE:. APPLICATION _ I�JIL�J`� (For Non-Transferable, Revocable,Suspendable) X�441t JU�j &MAVVELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ,)u f°,Q1J!N LOCAL Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the workHF-rgii d6ca6ST--f k aTplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 7.��, �7 �l G/>r;/s J4 _ City/Town Owner's Name LL �/i� !' C�h�Sli 1 Phone Address /I� jfh/� ) C1 City J-4 Contractor's Name o We21.,XLicense#,:? Business Phone e!-:1),Contractor's Address Emergency Phone Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No ` TYPE OF WORK (CHECK)' NEW WELLXi DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATiONW PUMP REPAIR❑ y REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank Sewer Lines ,5:b Pit Privy ) Sewage Disposal Field Cesspool/Seepage Pit _Other Property Line X�;' - Private Domestic Well Public Domestic Well + INTENDED USE r TYPE OF WELL 11INDUSTRIAL CABLE TOOL DiaC1 :of Well Excavation/51 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing f d fi ❑ DOMESTIC/PUBLIC .0 bR1 VEN Gauge of Casing —a d X IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ,r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 511/ C &,0/ ❑ DISPOSAL ❑ OTHER Other Information / ❑ GEOPHYSICAL Surface Seal Installed By: )I 5L5 c�s PUMP INSTALLATION: Contractor Type of Pump H,P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure d 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 certifles 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." 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." I will"it fora/Grout Inspection prior to grouting and a final inspection. Signed X �'� L.f' �/+r Title: ,/�e5VY 141-Wl-/D Date: 1'1�''3 — (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By �""`t © Date Additional Comment 1 Ph a 11 Grout Inspection �, h. Ill Final Inspection , Inspection By I Date Inspection By Date Fee Is Due: 13 ANNUALLY 11 PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receivyy ly31 BILLING REMITTANCE g REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED ,Q AMOUNT FEE B {� LESS PRORATION PLUS PENALTY 1 OTHER i OTHER Received by l5ate Receipt No. Permit No. Issuance Date .Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201