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Applications Will Be Processed When Submitted ProperlyC pled.Be Sure To Sign The Application. FOR OFFICE USE: APPLICAT ... —(For Non-Transferable, RevocabWi Suspendable)000 PVAP &WELL ENVIRONMENTAL HEALTk PE,RN1_5 1981 (COMPLETE IN TRIPLICATE) WATER QUALITY "Application is hereby made to the San Joaquin Local Health District for a permit to conss011ind"or install IiAe(vPOlUrein described.This application is made in compliance with San Joa um County Or man a No.1862 and the rules and rididtdatioA"If @e$e.r1~ oeTjuin Local Health District. Exact Site Address +� 3 sz g _ 7zr- -L.e. City/Town `Owner's Name 2�a,4 4io"a'a.. Gt/e"to Phone 3C�"�� -�' Address city ^ Contractor's Name - �t-a License#� ]� Business Phone Contractor's Address / `/ 0 .r �R+ Emergency Phone ��+G^F� r� CIA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ ..0 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage`Disposal Field Cesspool/Seepage Pit Other Property Line Private Domastic 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 ,n,,�yam Surface Seal Installed By: PUMP INSTALLATION: Contractor P� Type of Pump H.P. PUMP REPLACEMENT: 0 State Work Done PUMP REPAIR: State Work Done DESTRUCTION OF WELL: - Well Diameter - Approxim a 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 y .— ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. V Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit V 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:"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 I call t r a Grout ecifon prior t grouting and a if net inspec on. Signed X a a�rNle: - ' /1✓ Date: (Draw Plot Plan on Reverse Sf e) (e' i F&t DEPARTMENT USE ONLY ` PHASE I ft �nn � A� rfpT�� 7p� Application Accepted By I V, Date v ", Additional Comments: P Grout a s_t Inspection III Final Inspection Inspection By Date � � Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 REMIT V BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DAVE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER s� Imo. Received by Date Receipt No. Permit No. Isaliance Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAi ELTON AVE.,PA.Box 2009 STOCKTON,CA 95201