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vv,,,yv,cu. vc uury tvIrrG�Y�I ;uW. V /.� FGR OFFICE usE: APPLICATION LLJJ ! I I v,For Non-Transferable,Revocable,Suspendable� PUMRI& ELQ81 ENVIRONMENTAL HEALTH PERMIT r JUU GNV (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ;N LLn''`kL Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work is made in compliance with Sa Joaquin County-O�dinance No/ 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address IL /[j/i� RO Town y / N j e_jy Cit Owner's Name - �to Phone 1' -- ,o0 Address -- aZ � " 11 � T l City— Contractor's � Contractor's Name —` , _, - S S� - License#dQ�&0 Business Phone =22d-7 Contractor's Address EmergencyPhoneu�1Ll Yrn'Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑- RECONDITION❑/A DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR V REPLACEMENTPI DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy UJ Sewage Disposal Field - Ceslipool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE, TYPE OF WELL VJ 1�1t INDUSTRIAL -- -0 C.A�E TOOL Dia.of Well Excavation Pr( 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 tnformalion -- ' ❑ GEOPHYSICAL Surface Seal Installed By_. PUMP INSTALLATION: Contractor ,�.vpYTly1pe of Pump H.P. Y PUMP REPLACEMENT: State Work Done-46e 61.d.✓-C T eC 'L, PUMP REPAIR: ❑ State Work Done T 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.': _ Home owner 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 W"ll for rout pnor to grouting and a final inspect Signed X - Title: T Delta: (Draw Plot Plan on Reverse Side) 1pn�n\ V� FOR DEPARTMENT USE ONLY PHASEI Application Accepted BYNI L AI-1, Date Additional Comments: MMPhase It Grout Inspection Phase III Final Inspection Inspection By Date Inspection Bye Ce---_ _ Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January t&Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION -. PLUS PENALTY OTHER OTHER to 4 I )1SB b- -rc Received by D to I Receipt No, Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16el E.HAZELTON AVE.,P.O.Boa 2009 STOCKTOK CA 95201