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Dia. of Well Excavation 0,2S7 <br />Dia of Well Casing /6" <br />Gauge of Casing /la) <br />Depth of Grout Seal <br />Type of Grout /lOne., <br /> Other Information k•-'0-.A6 — ab/ er24_2 <br />Surface Seal Installed By: /70,te_.../ <br />H P <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENAI Ty <br />°THEN <br />OTHER <br />REMIt -- <br />CHECKED <br />AMOUNT REMITTED <br /> <br />AMOUNT DUE <br /> <br />REMITTANCE <br />DATE <br />FOR OFFICE USE; APPLICATION <br />(For Non-Transferable, Revocable, Suspendable) <br />PUMP & WELL <br />ENVIRONMENTAL HEALTH PERMIT <br />(COMPLETE IN TRIPLICATE) 1136C 4WILIAmtry... WATER QUALITY <br />._ <br />Application is hereby made to the San Joaquin Local Health District bra permit to construc.t and/or install the. .ork herein described. application is <br />made in compliance WI San Jo?quin igity Ordinance No <br />Exact <br />-217d the Astn <br />Exact Site Address / t5/4177/X., _a -.660%,0 . <br />regul• tion,$)161;5tAr Joaquin_pcy,2th D <br />This <br />yityll%vv ril L <br />Phone <br />&AS/a/et ?lie 45f0Emergency Phone 63/5 a2 7/ <br />(-2/1,9•12-) License # agog/3 Business Phone S —49/496- <br />Is Certificate of Workman's Compensation Insurance On File With SJLHD? Yes 1.0. No <br />TYPE OF WORK (CHECK): NEW WELL' DEEPEN El RECONDITION DESTRUCTIONEJ <br />WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION 0 PUMP REPAIR 0 <br />REPLACEMENT Li <br />DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />Sewage Disposal Field <br />Cesspool/Seepage Pit Other <br />Property Line Private Domestic Well <br />Public Domestic Well <br />INTENDED USE TYPE OF WELL <br />CI INDUSTRIAL El CABLE TOOL <br />DOMESTIC/PRIVATE 0 DRILLED <br />El DOMESTIC/PUBLIC <br />9FilVEN <br />7,34RRIGATION W'GRAVEL PACK <br />CATHODIC PROTECTION [340T ARY <br />DISPOSAL Li OTHER <br />GEOPHYSICAL <br />PUMP INSTALLATION: Contractor <br />Type of Pump <br />PUMP REPLACEMENT: 0 State Work Done <br />0 State Work Done — PUMP REPAIR: <br />DESTRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District <br />Nome owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit <br />is issued, I shall not employ any person in such manner as to become subiect to workman's compensation laws of California ' <br />Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance at the work for which this <br />permit is issued, P shall employ persons subject workman's compensation laws of California." <br />Signed X <br />w' I call bra Grout <br />Ieia4 <br />t/..."Pection priobliio grouting a final inspection. <br />, Date: <br />(Draw Plot Plan on Reverse Side) <br />t-;Lh Vo EE <br />FOR EPARTMENT USE ONLY <br />PHASE I <br />Application Accepted By <br />Date <br /> 77. <br />Additional Comments: <br />Owner's Name 'lea 11,,it. 1 , <br />Address /6-ii, 0 .• 0. 1.0 <br />Contractor's Name jii-e-14-41,„! <br />Contractor's Address _ .0595" <br />-36eYzz <br />Approximate Depth <br />U1LL NO <br />RATE <br />hase II Final inspection <br />Inspection By IA _ odte 1 <br />4 ey January 3 0 Jiity 1 6 Received By Li . <br />,/ <br />Issuance OaIi Maiitid Drill:Tr.? el <br />Phase II Grout Inspection <br />Inspection By <br />Fee Is Due: El ANNUALLY CI PER <br />UASE EXPLANA'1ON <br />FU.iTL 0 LACH 0 January 1 6. <br /> ,/,y/ ( / I 7,;), —- 71= \3So Ri:tnvrr, by Dal.? Re.0316t Ni Pre•tIll! Nu <br />APPL1CANT TRETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERIAFTSERVICES 1601 E NAZELTON AVE., P.O. Box 2009 STOCKTON, CA 952(11