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nppncauuna winoerroceasva wnen auumuvra rrupenyS umplvlva. oeaur&u amyn 911CerIJFIIwLIV91. FOR OFFICE USE: APPLICATION kk4V 00 be r✓ e,",11*Tfor Non-Transferable, Revocable,Suspendable) P&WELL ENVIRONMENTAL HEALTH PERMIT r L_ (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install thework hereindescrib .Thisriations made in compliance with San Jo uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addressor ..�t:.•� a'wyw. [ [f�.tL �il.l.��rr-d dl City/Town s( Owner's Name+4 Q h _IA4[rrs k zr C17Za7/>:a•v�.c d� 7+Lr 7h431 Phone�/c /- �'41 Ro's— Address �n /Jn,.,i y /ra:._r n L City Contractor's Name Q License fi/G 237? Business Phone 26?-JrT f Contractor's AddresEmergency Phone -y6d—!`L 2.1� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ^/ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ pd DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other— Property ther 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 ❑�yDOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing RlRRIGATION _ .❑.GRAVEL PACK....._ -„.Depth of Grout Seal . � ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL �• Surface Seal Installed By: PUMP INSTALLATION: Contractor z-Z { Type of Pump H.P. PUMP REPLACEMENT: ❑ St6,te Work Done PUMP REPAIR: liS/tate Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I I hereby certify that I have prepared this application acid 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:"1 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California:' I gilyyall f r a Gro napeetion prior to gro Ing and Ia,final inspection. Signed X Y N1 Title: ;/I " — Date: (Draw Plot Plan on Rever Side) FOR DEPARTMENT USE ONLY f PHASE Application Accepted By .1--y-� Date Additional Comments:— Phase omments:Phase II Grout inspection jhas 1�1 Final Inspect1 Inspection By Date Inspection By/ Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 5 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE C/Y LESS PRORATION PLUS PENALTY OTHER OTHER S 3 acs _N-3-AOD- I Received W Date Receipt No. Permit No. Isaua a to Mailed Delnerad i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTON AVE..P.O.BOX 2009 STOCKTON,CA 95201