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y ^VP,WOUVI,a ..,,, J FOR OFFICE USE: yAPPLICATION ,For Non-Transferable, Revocable, SuspendablL�` dv _ &WELL ENVIRONMENTAL HEALTH PERMIT '//p (COMPLETE IN TRIPLICATE) WATER QUALITY `SiA..�',ll Rjii"i'i -'t"�'N LOCAL Application is hereby m tah�e an Joaquin Local Health District for a permit to construct and/or'iASC 4T WoP1hC/0i1rMecribed.This application is made in compliance wit an Jlquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address JY/Lf�/SiSr 4ALJ�VT/9lE' City/Town ��C'.�TO/tt! Owner's Name V-Anawloi ' 'Tt/'f' Jamt Phone Address 9;x49 5 , H/wfti=E'vv Gam' -�� C�ity4v— rery .� c/ 9Ss7�s Contractor's Name License N+��.3- usiness Phone ' ' -� Contractor's Address Emergency Phone 15; Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Z� No ^I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -(Z WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /'-7t! Sewer Lines Pit Privy Sewage Disposal Field i Cesspool/Seepage Pit Other Property Line /A� Private Domestic Well /SlJ"Public Domestic Well INTENDED USE TYPE OF WELL X INDUSTRIAL CABLE TOOL Dia. of Well Excavation /ago �ieSr SO1 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 9W ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing O ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat qz� ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout y 5 i- T 0404e= 1 ❑ DISPOSAL ❑ OTHER Other Information - ❑ GEOPHYSICAL Surface Seal Installed By: �7/ice-SO•t0 ^ PUMP INSTALLATION: Contractor `o .J AlM,0! �ACrOA Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done r 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I wit all fora Grout Inspection psior to grouting and a final Inspection. � Signed X « �� p Title: ( Date: ��'�"�O 2� (Draw Plot Plan on Reverse Side) `n FOR DEPARTMENT USE ONLY PHASE I ` � Date Www PM \�^ ®I-� 40)y Bt;, Application Accepted By l � , 1, 1�"III Additional Comments: l me rout gspectionG,�f��i Phoma/sa III Final Inspection Inspection By 4. Date moo/ Inspection By - N°^ Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED 2 AMOUNT FEE v LESS PRORATION PLUS PENALTY OTHER OTHER D!� Received by Date Receipt No. Permit No. I uane Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1551 E.HAZELTON AVE.,P.O.soa 20001 STOCKTON,CA 95201