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Applications Will Be Processed When Submitted Properly Completed _)sure To Sign Tpe d ation. FOR aFPE 13SE: APPLICATION `_., rTE (For Non-Transferable, Revocable, Suspendable) &WELL tENVIRONMENTAL HEALTH PERMIT 4.5 IN TRIPLICATE) 2�-�p �. ,tet , ) :� iLWATER QUALITY wok Application is hereby,made to the San Joaquiri Local Health Districtfora permit to construct and/or install the work herein described.This application is ' made in compliances ywith San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sa Joaquin Local ealth District. I Exact Site Address 1'f 1' "W0, 4 -R(A.. see- City/TownI r Owner's Name & tU Lc, Phone 1(0 'L-4t 3 ' Address 514 Ski a City & Cr'K- v v+. Contractor's Name 1 "'C IV-- SYS ["% License#3"q"57'X�_ Business Phone-e_1{ Contractor's Address 0 ' Emergency Phone �� " Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No �. TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �3 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. } i REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/seepage Pit Other �C_ cx i Property Line _ Private Domestic Well Public Domestic Well + 1 INTENDED USE TYPE OF WELL ` 11 ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation f ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information f ❑ GEOPHYSICAL Surface Seal Installed By: LA s . PUMP INSTALLATION: Contractor OVlev-IZ� ,TypeofPump_ 3k.-ItiP - Wc[( \%Av-btAfc� H.P. S + PUMP REPLACEMENT: ❑ State Work Done- PUMP REPAIR: State Work bone —.. 1 DESTRUCTION OF WELL: Well Diameter Approximate Depth � Describe Material and Procedure' L� 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 certifies the following:"I certify that in the performance of the work for which this permit ro is Tissued, t 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." / lI 1 will call for a Grout Inspection prior to grouting and a final inspection. � Ije eel v- 1YY•1 y,rt l�'^- ` 'TiH � Signed X Title:!: U"12 &A fll`A) S"t p . C/Date: (Draw Plot Plan on Reverse Side) FORD PARTMENT USE ONLY PHASE I �f l Application Accepted By �% �'' ^^ I (5 r Date � Additional Comments: Phase 11 Grout Inspection eal51�alnspection f Inspection By Date Inspection By Date e_t1,2 w # Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 5 &Received,By Ju BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNTDUE CHECKED I DATE DATE REMITTED AMOUNT t FEE j LESS PRORATION PLUS PENALTY' THER L- y/ hzi_T HER ryt .�� Received by• t Dat -,r `-:V►s -Receipt No.-' Permit No. Issuance Date Mailed Delivered 7 ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES' ^ 1601 E.HAZELTON AYE.,'P.O.Boz 2009 STOCKTON,CA 95201 '