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FOR OFFICE USE: APPLICATION -- r, (For Non-Transferable, Revocable, Suspendable) P tV1i, WELL -- ENVIRONMENTAL. HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to con truct and/or i60,r gffiwork herein described-This application is made in compliance wit an Jo uin unty ce No. 1 62 an he ru es /regulations � Joaquin cal Heal Di Exact Site Address tr/1 :S] Z ►C j — - Lc�(c �(Sitty (� Q�� - ��LL Owner's Name . (i2 t� L C Phone Address -- -- �... AC ?�� ka - . City_ !•�G�eZ -- - - Contractor's Name -5 License #CZE_o_ F1.3 Business Phone,._6w Contractor's Address_ j},S ILQ�j� QC, 1�s]`Z' ,ergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes // No _ -T TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION© 02-7 F-ST fQ FS WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION © PUMP REPAIR❑ REPLACEMENT❑ D#STANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well --. Public Domestic Well _ INTENDED USE TYPE OF WELL © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation--(- El xcavation❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing ._.--. n t1O&I STIC PURI IC ❑ DRIVEN Gritic of Casing r ❑ IRRIGATION ❑ GRAVELPACK Depth of Grout Seal ❑ CATHODIC PROTECTION Q-f 'OTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump __. H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done - _-__-- DESTRUCTION OF WELL: Well Diameter _.- A roxi ate Dept _ Describe Material and Procedure 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. Homeowner 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 as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:A certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensation laws of California." — ... .=. , I w f call for a.Grout 1 sp clion prior to outing a�Id a f' I inspec Signed X_/` i 4 K'L ��. �n le:L -,o-/ L-`l C-�, N� Date: (Dr w lot Plan on Reverse Side) ��_�_7g FOR DEPARTMENT USE ONLY PHASE [ - - Application Accepted B -_ — . _ Date// �.1�� Additional Comments: C p;, _ 1� " ase 11 Grout Ins pecllonrrk,,�, G Phas 111 FMal Inspection n pection y __ Date Inspection 8y Date Fee Is Due: ANNUALLY ❑ PER UNIT PER SITE EAH -❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 F — REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED_ AMOUNT FEE A /L!j �.a ,t/4'Ft�r�,. r ----- LESS /V PRORATION PLUS -�1•-t ' PENALTY 3ti OTHER OTHER 1r ' I =_1j1_ ReGesved by Dele I Receipt Nb. Pernul NO. ILI uan. UalO Mai$ad Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITl5ERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 4