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Applications Will Be Processed When Submitted Properly Completed.B64 Cc&i�'A 6 'n A' ,0dpp4ica&ll6.a FOR OFFICE USE: APPLICATION ) ' rr (For Non-Transferable, Revocable,Suspends l y Q(�/ l�L�M1ELL ENVIRONMENTAL HEALTH PERMIT JOS,_(00� �� ItZF�C%UIN LUL L (COMPLETE IN TRIPLICATE) Z2; y.N a(t t- Mf, T QUAUTY s SAN t { T Application is hereby made to the San Joaquin Local Health Di fora permit to con`s'truct and/or install t �JcTtWre 1d%$c�rlbed.This application is made in compliance with San Joapuip C)unty Ordinance No. 6 n the rules r Ula'ons of the San Jpaquin L_ojaI Health District_ Exact Site Address r 7 Sf City/Town F r Y! g ui Owner's Name l v� it•sit '' !t:+ �. • Phone_ � �-�/ -^ 3 Address - • ( r City_ �- ) w a o Contractor's Name -.Z.- License s# Q V&usiness Phone Contractor's Address .Zz:. Emergency Phone Is Certificate of Workman's Compensation insurance on Flle With SJLHD? Yes L`� No TYPE OF WORk (CHECK): NEW WELL K DEEPEN d RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 PUMP INSTALLATION Pf PUMP REPAIR❑ CIO I REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Liries p � Q Pit Privy Sewage Disposal Fipld Cesspool/Seepage Pit Other CY Property Line_Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL Je n 1 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of-Well Excavation gDOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing feR ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Q ❑ CATHODIC PROTECTION ROTARY Type of Grout io✓ ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: __ e PUMP INSTALLATION: Contractor wt Type of Pum❑ H P V. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure _ 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 �r 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 for which this permit is issued, I shall employ persons subject to work man's'co In pensation laws of California." I or a Grout Ins I pectlon prior to grout` and a al inspection. Signed X. itis: Date; ~ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY Application Accepted By Dale 5 Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By'?t-f Date 1d/��/j� Inspection ByDate Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 REMIT - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE1416 `/ — NO 16-1-to ae_4 11 LESS ' �I o •toric-c-far.• Yom; r-a.P� GaN•' �-e - PRORATION f PLUS . .. PENALTY OTHER OTHER z { Received by Date •Receipf No. - Permit No. '.Issuance Dae Mailed Delivered' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201