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FOR OFFICE USE: APPLICATION .I For Non-Transferable, Revocable, Suspendable ENVIRONMENTAL HEALTH PERMIT /// .' A&WELL QUALITY -_t WATER om (COMPLETE IN TRIPLICATE) Q ` Application is hereby m tah�o``SSan Joaquin Local Health Districtfora permit to construct and/orri"'stall the work herein described.This application is made in compliance�wi ddaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 4.r 0 5 /i 99F/Zf.N/��(j� City/Town 15,-fJC.-7-r;S Owner's Name 'D/ TL1,eA- T;(/T. 1.it/C', Phone — _ Address ��Z 5 • Ff/Wi1+T �ie0iVY7 .yfa City 7'T77L`1'. �/ C✓"�4� �-�`,A''� Contractor's Name License# usiness Phone;? 3377(,I'11 Contractors Address _AL3 ,('' 3 C`L6'.r2i� TS Emergency Phone 7_1=2`, Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L/ No ^( TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 755- Sewer Lines Pit Privy Sewage Disposal Field Ili Cesspool/Seepage Pit — Other Property Line /lf/J Private Domestic Well //S!J Public Domestic Well INTENDED USE lIa�r TYPE OF WELL �INDUSTRIAL p CABLE TOOL Dia. of Well Excavation /,g~ f/,BST $O� /❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing g•/ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing O ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal O ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout S SA i T C7 eLT- ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: CS/i1Say PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done rim 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California" I wg all fora Grout Inspection Wor to grouting and a final inspection. �1, - Signed X cr] Title: 5e, ®-AJC - Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I � ��'''"" QQ��((��\\ ��j�pp�� II.. hK f'� S- Application Accepted By `L1L[1lsaa 1 1 1 0^""��^® ` Date 1 1 "j`^�`^�® ` Date D Additional Comments: ax I rout pectlon Pha III Final Inspection Inspection By 49 � � Dates��A Inspection By - �� Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE V o LESS PRORATION _ PLUS PENALTY OTHER OTHER tf li/ Received by Date Receipt No. Permit No I uanc Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES felt E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201