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ICOR OFFICE USE: APPLICATION EP1 x Non-Transferable, Revocable, Suspendable) L L ENVIRONMENTAL HEALTH PERMITSA jpp,QON LPkT WE (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRIvT ,;application is hereby madetothe San Joaquin Local Health District for a permit to construct and/or installthework herein described.This 2pPli catior made in compliance with San Joav4in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health Dist r-ict. Efact Site Address 4700 E Mariposa Rd. City/Town Stockton Eugenia Murchison Phone qY o �f 9 Owner's Name - Address • • City' 0 9 Contractor's Name Machado,In. . -..= License#3770 0us ness Phone 2.I 2 Contractor's Addres N. one . Emergency Phone 8463-3002 Is Certificate of Work ensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENTM 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 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing O IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: X ❑ State Work Done Installed 1J HP 1;Ubtn rppl;tnF- n1d pi PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: Well Diameter Approximate Depth 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. 7 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 subcontracting 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 all all for a Grou /1sp tion pIf I outing and a final inspection. Signed X J'n� � a i(O Title: OWrier Date: (Draw Plot Plan on Reverse Side) ��------ FOR DEPARTMENT USE ONLY PHASE[ (�� Application Accepted By " , ` O� Date Additional Comments: OL. Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED !,,i AMOUNT FEE yS� O Y` LESS PRORATION /I-w PLUS PENALTY OTHER OTHER m Bt OCT 1;;-3 Received by Date Receipt No Permit Nolaau nee Datb Mailed. DeliveradU APPLICANT—RETWIN ALL COPIES TO: ENwRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA San ..