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Applications Will Be Processed When Submitted Property Completed. ure To 31pn The Appllca�i�� FOR OFFICE USE: APPLICATION ^/ o (For Non-Transferable,Revocable, Suspendable) JAN G PJJX;9�&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUAUTT SAN JOA.IQUU( INNG LOCAL Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or ins�k fYAU iles`oTbed.This application is made in compliance with San,J quin County Ordinance No. 1862 a�Qd)he rules and regulations of the San Joaquin Local H@alth District. Exact Site Address�77J r VI SY 00 AL1.;7V Kd)� L City/Town sly.)i/.��✓ Owner's Name �) Iti rFL', P // n C,: Phone Address City— Contractor's ity Contractor's Name Vti License R-2il 113 Business Phone 6381 e><J Contractor's Address y n Emergency Phone Soo a-.-*_ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A114 No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ CJ 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 Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation R DOMESTIC/PRIVATE ❑ DRILLED Dia.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 ❑ GEOPHYSICAL Surface Seat Installed By: PUMP INSTALLATION: Contractor Type of Pump 37 - H.P. PUMP REPLACEMENT: LN State Work Done n-[ -v.wk.< S 1 P d S PUMP REPAIR: 11 State Work Done 1 v "F DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure C/ 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. gG Homeowner or licensed agent's signature certifies thefollowing;"I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Con"clor'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 haws of California." AREA O'Q I w II f4 r a Gr t Insp ion prior to grouting and a final Inspeclil TQ7 Signed X Title: tti -(! (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI � Application Accepted v Data "19z-- Additional Commen�� 0 Phase 11 Grout Inspection Phan 111 Final Inspection G Inspection By Date Inspection By G ate a Z- Fee Is Dub ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 18 Received By July 31 REMIT BILLING REMITTANCE S BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE 9r 's40 lir o T[�S LESS PRORATION PLUS PENALTY OTHER OTHER -fn i �� 9ya l�0 95 Received by bme Receipt No. Peroil No. balance Date Mailed DelivereE APPLICANT—RETURN ALL COPIES To: ENwRONMta ft HEALTH PERMIT/SERVICES INN E HA2aLTON AVE.P.O.So.20x9 STOCKTON,CA ssain