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ten Submitted Properly a Appllgtiohs'Will Be Process �`. 21 \ v APPLICATION �/M FOA OFFICE USE: LW Ju� �� , -- r.- (For o i*sferable,Revocable,SuspencJ � ¢UMP&WEIL y�lr< [�IK[➢i6f4MENTAL HEALTH PERIi q -- ATER QUALITY }7 6�1 r -srw, (COMPLETE IN TRIPLICATE) -d Ic dy4rein described.This application is Application is hereby made to the an Joaquin Local Health District fora permit toconstruct and/or l tall the vrlf�*a made in compliance with San Joaqui0 unty Ordina ce No. 1862 8/►6�2 and the rules and regulations of the San Jo�'qui Local Health District.— — S, / �� 1fjto _ Cityr'Town _ Exact Site Address I — — -- — — 4 Owner's Name Phone_. �•� — Phone Address _. '�r7Q Business Pcity hone= — ---�— License IF Contractor's Name Dt�.})/�L£,p6�U�/ I !a t� - Emergency Phone {n Contractor's Address _1&-&-4 �-, —" octz�- -I'� No v l _ t Is Certificate of Workman's Compensation Insurance on File With SJ LHD7 Yes — TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT J4 OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ Pit Privy _ ---- f DISTANCE TO NEAREST: Septic Tank _ — Sewer Lines — — - - l Sewage Disposal Field__ — Cesspoo!Seepage Pit _ — Other —._.. k Private Domestic Well — — Public Domestic Well— .5-- Property Line _� ODEDDED USE TYPE OF WELL Casn TRIALCABLE TOOL Dia. of Well E —❑ DRILLED Dia.of Well CSTIC!PRIVATE Gauge of Cas -- STIC"PUBLIC ❑ pRIVEN TION _ ❑ GRAVEL PACK Depth of.Gro❑ ROTARY '. Typeof.GrouDIC PROTECTI NOtherInform — — SAL ❑ ETHER —Surface SealHYSICAL _TALLATION Contractor _-_— .Type of PumpENT: ❑ State Work Done— — r C1 state Work Done — PUMP REPAIR — , --- —, _ Approximate Depth — DESTRUCTION OF WELL: Well Diameter ---— — — — I Describe Material and Procedure_ _-- cordance with San Joaquin County — I hereby certify that I have prepared--this application and that the work will be done In ac r 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 P 1 s of California."is issued. 1 shall not employ any person-in-such manner as to become subject to workman's compensation law following:"I certify that irf the performance of the work[or which this Contractor's hiring or sub-contracting signature certifies the I permit is issued. I shall employ persons subject to workman's compensation laws df Calilornia." t I will call for r Inspection prlor-to grouting and a final inspection. -/- _ ' 'Title: Date: Signed X (Draw Plot Plan on Reverse Side) { J�, FORDEPARTMENT USE ONLY PHASE I �'g � DatetedB r Its I Application Accepted Y - —_— Additional Comments. —� --- — phase I Final pection Phase II Grout Inspection _ Date — — I .w ; f-- Inspection By Inspection By_/��1�"" Date— Fee IS Due: ❑ ANNUALLY ❑ ITR UNIT ❑.PhR SITE ❑ LA.^,H E] Janaary 1&Recero5d By January 31 ❑ July i d Receivt.d BY=u'Y 3' — f{EMIT Hit LING aEMIT TANCE 5 AMOUNT DUE CHECKED BASE EXPLANATION DA1F DATE I REMITTED AMOUNT.,_...— _ ._.___....._ LESS PRORATION - 1 — PI i1S -- PENALTY I OTHER — OIHER — --f— -- — — 7U1 —.� ----- —lys aRce DaC Matied— Delivered 'L-- Date Ar.Cel pt No Prrmll^1c. — _ Received hY 1661 E.HAZELTON AVE.,P.O.Bo*2009 STOCKTON,CA 0201 APPLICANT—RETURN All COPIES TO: ENVIRONMENTAL HEALTH PERMIT.-SERVICES' -