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Applications Will Be Processed When Submitted Properly Completed.-Be Sure To Sign The Application, FOR OFFICE USE: APPLICATION � ��•'lV_10 � I _ (For lion-Transferable,Revocable,Suspendable) �+ ENVIRONMENTAL HEALTH PERMIT 3�,11l NED WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work•herein described.This application is made in compliance with San-Joaquin County Ordinance No•.1862 and•the rules and regulations of.the San Joaquin Local Health District. Exact Site AddressAratg Rd City/Town Stockton I t. Owner's Name Ri r'-k_Arata Phone Work 931-1470 Address ' ' —,-6935 Vi 7 1 a�Q CrePn City Stockton Contractor's Name f'1 ark Wi-i 7 & re'I mien -�---•� �,�_License# � � S6Q Business Phone �F62- Contractor's Address ?t1?1J.' F, f'hartlir Wray Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No TYPE OF WORK(CHECK): NEW WELL " DEEPEN❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ N REPLACEMENT❑ ; DISTANCE TO NEAREST:_ Septic Tank 5J0___ Sewer Lines Pit Privy ' Sewag6 Disposal Field_ Cesspool/Seepage Pit Other Property Llne 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 ( VB" ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 9 2 Steel ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Ek ROTARY Type of Grout Bentonite ❑.DISPOSAL .."El-OTHER _ Other Information. ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: ,Contractor y 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 �}r 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. y 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 sub-contracting 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." FIall for a Grout Inspection prior to grouting and a final inspection. Signed X �I art,d Title: (Draw Plot Plan on Reverse Side) ------------ FOR DEPARTMENT USE ONLY PHASE 1 'r. Application Accepted B �VY� a Date ;aGf 2 Additional Comments: _ _ / a .II Gr ui Inspection Phase III Final Inspection Inspect'D By_f't c Date f-b Inspection By a Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE ~~ AMOUNT LESS PRORATION d PLUS PENALTY , v OTHER i OTHER I ; Received by Date Receipt Na Permit No I suanc ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO:• ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK70N,CA 95201