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USE: AF'F'L.I UA 1 I V N —FOR OFFICE (For Non-Transferable, Revocable. Suspendable) r,Jy✓ PULP He WELL ENVIRONMENTAL HEALTH PERMIT Y v (COMPLETE IN TRIPLICATE) WATER QUALITY "JJ Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San J -quin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address •h-�r��_� ��^ " =L 4a- CityiTown Owner's Name Phone Address � / City- License ity I p�� — — — Contractor's Name _ e ��.'" — License ii�L� �1�— Business Phone ,�+�-� 6� Contractor's Address _ /. 3y .' - _ Emergency Phone � Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '� — No TYPE OF WORK (CHECK) NEW WELL❑ DEEPEN EJ RECONDITION 1:1 DESTRUCTION WELL CHLORINATION 11WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION @-/ PUMP REPAIR REPLACEMENT❑ C DISTANCE TO NEAREST: Septic Tank ._ Sewer Lines — Pit Privy — p Sewage Disposal Field_ — Cesspool/Seepage Pit _ Other — — Property Line_ Private Domestic Well _ Public Domestic Well— — — — INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CA13LE TOOL Dia. of Well Excavation— --- — — — ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing — — — — ❑ EIOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — — — ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ ❑ DISPOSAL ❑ OTHER _ _ Other Information— —--— — ❑ GEOPHYSICAL Surface Seal 1 stalled By - PUMP INSTALLATION: Contractor Type of Pump / H P. _ PUMP REPLACEMENT: ❑ State Work Done -- PUMP REPAIR: ❑ State Work Done —. -- 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. Homeowner 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 anv 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 m the performance of the work for which this permit is issued. I shall employ persons subject to workman's Compensation laws of California." I 7::7 all f r'a_Grou`t pectlon p ''or to grouting and a final inspection. Signed X 7 �` �2-E�� — Title: Date: (Draw Piot Plan on Rev�ide) FOR DEPARTMENT USE ONLY PHASE I l rj+p0 Application Accepted By Date ` — Additional Comments -- - -- — — — — -- Phase II Grout Inspection Phase III f'f of�apecilon [' Q�� Inspection By—,T-f� F'aw -- Inspection By, �{v{ ``�t�eate —.ti2-1�L— Fee Is Due:❑ ANNUALLY ❑ PEP.LiNI- ❑ PLR S;'E ❑ FACH ❑ Jan.ary 1 S Rec y Jfrtubry 31 ❑ Juty 1 d Received By J-_IY 31 1-- _ _— �' — — - REMIT BASF FXPLANA'ION UILL1NC I nERMTTANCE 3 AMOUNTDUE CHECKED DAZE OA-E REMITTED AMOUNT FEE Av _ - PRO ATION --- PENS PENALTY —. --- OTHER O I HERI — Received by Dato 4ece•pr No Per•nrt No Issuance Date Maded� Dehvcred APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAMILTON AVE..P.O.boy 2009 STOCKTON,CA 95201