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Applications Will Be Processed When Submitted Properly Completed. Beg,4To Sign Th�T I'c�(jon.C_:J —FOR OFFICE Use:- APPLICATION iiii�UG L� (W (For Non-Transferable,Revocable,Suspendable) SL ENVIRONMENTAL HEALTH PERMIT SAN f^'riS f�l�i'T �"✓ELL 19rJ`,L►ri Dfni�iR!C7 (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applization is made in compliance with Sin Jua/quin CoL�n,i{y Ordinance No.g1862 and the rules and regulations of the San Paquin Lpcal Health District. Exact Site Address -2: �6. t'� Vii^X�O J City/Town ki.v Owner's Name��W� r-Qj�� 5 U _ ___ - _ _ Phone Address ��!—_�S+�rWOUI:I - — -- — — City G...`,C•4--,V\-\ ---OCI 6 Contractor's Name Y►�_`r�r -___-��_'_ _ License u-3S�y_b.YBusinesj�hone Contractor's Atldress .IQ.f"�G__—.0 le��' ^e� <j""''I` Emergency PhoneIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No —_ TYPE OF WORK(CHECK): NEW WELL DEEPEN❑ RECONDITION U DESTRUCTION 13 47— WELL CHLORINATION ❑ WELL ABANDONMCNT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE 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 _ — _WIDOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC 1:1 DRIVEN Gauge of Casing -- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout — ❑ DISPOSAL ❑ OTHER __ Other Information ❑ GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: --- Type of Pump H.P. --- a PUMP REPLACEMENT: ❑ State Work Done_.__ _ — --- PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter-__----._.-_ Approximate Depth—___— ?: Describe Material and Procedure ---- -- — Y t hereby cert,fy 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 fur 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 certilies the following:I certify that in the performance of the wore;for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grou Inspecttllon.prior to grouting and a final inspection. ( c Signed X _ �y�~ Title: _ ��' ✓`^ __ ___ Date: . (Draw (Draw Plot Plan on Reverse Side — FOR DEPARTMENT USE ONLY PHASE I W 8_J..6-BC1 Application Accepted By Date - Additional Comments: — Phase II Grout Ph se 111 Final Inspection Inspection By—l�_1�— Date_ —_ Inspection By s�. Date ty Fee fa DUB:❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑EACH ❑ January 1 6 Re.:eived By January 31 ❑July 1&Reuelved By July 31 — --- -----" -- - --- REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED r/�' AMOUNT FEE -- -1� ------ — — _.—. 1'S O� -- LESS PRORATION -- - PLUS PENALTY __ ------- ---- - OTHER --— II ---- _ OTHER Received Dy — --Oars Receipt No Pe-1 o /issuance ate Maded Deiwered APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMITiSERVICES 1601 E.NAZELTON AVE.P.O.Box 2009 STOCKTON,CA 95201W -