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INTENDED USE <br />El INDUSTRIAL <br />DrDOMESTIC/PRIVATE <br />El DOMESTIC/PUBLIC <br />IRRIGATION <br />El CATHODIC PROTECTION <br />DISPOSAL <br />El GEOPHYSICAL <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />Owner's Name 411-VAS 044/ <br />Address 73/7 Ci a4Arr Ai city <br />Contractors Name _L61,1.2,01 License lf ,12.1 94:Z Business PhoW 63_2 —798.2 <br />Contractor's Address <br /> <br />Emergency Phone <br />Is Certificate of Workman's Compedsation Insurance on File With SJLHD? Yes X No <br />TYPE OF WORK (CHECK): NEVX./ WELL. DEEPEN 0 RECONDITION 0 DESTRUCTION 0 <br />WELL CHLORINATION 0 WELL ABANDONMENT ID OTHER 0 PUMP INSTALLATION 0 PUMP REPAIFI 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST: <br />Z5/0 ,S;!. <br />11 <br />Septic Tank 157 A77- Sewer Lines Pit Privy <br />ii <br />Sewage Disposal Field /00 Fr, Cesspool/Seepage Pit Other <br />il Property Line Private Domestic Well Public Domestic Well <br />TYPE OF WELL <br />• CABLE TOOL Dia. of Well Excavation 1/ <br />DRILLED Dia. ol Well Casing 61' <br />DRIVEN Gauge of Casing fix- /O <br />ilCGRAVEL PACK Depth of Grout Seal <br />• R ROTARY Type of Grout _S5SMAL/7772 <br />OTHER Other Information <br />Surface Seal Installed By: <br />Contractor <br />Type of Pump H.P. <br />State Work Done <br />State Work Done <br />Well Diameter Approximate Depth <br />Describe Material and Procedure <br />Phone <br />REMITTANCE <br />DATE REMITTED <br />' AMOUNT DUE <br />Receive° by Date] ' <br />PPLICANT—RETURN ALL COPIES TO: <br />Receipt No. Permit No <br />ENVIRONMENTAL HEALTH PERMITSERVICES <br />0 EACH 0 January 1 & Received By January 31 Fee IS Due: 1:1 ANNUALLY cse. PER SITE 0 July 1 & Received' By July 31 <br />REMIT <br />CHECKED <br />AMOUNT <br />EXPLANATION BILLING <br />DATE <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />FOR D PARTME USE ONLY <br />PHASE I <br />Application Accepted By <br />Additional Comments: <br />Inspection By <br />Ph s II Grout Inspection <br />Date Inspection By <br />&ae—j--44 <br />Issuance Dare Mailed Delivered <br />1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />Date <br />e III Fin 'Inspection /// <br />bate <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />OR_OFCE USE: APPLICATION <br />(For Non-Transferable, Revocable, Suspendable) <br />PUMP & WELL <br />ENVIRONMENTAL HEALTH PERMIT <br />c2- NATER QUALITY I 3— -0-7 o ..- c2-- <br />Application is hereby made t ; oaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br />made in compliance with San Joaqu n Cou Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br />Exact Site Address MLADD ".2 .- - 717 7..? i 7 OgiktriVetiq/Town 7.i4C3 --Dr) . , . <br />COMPLETE IN TRIPLICA <br />-et <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 />Home owner or licensed agent's signature certifies the following: "I 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 subject to workman's compensation laws of California." <br />Contractor's hiring or sub-contracting signature certifies the following: "I certify that In the performance of the work for which this <br />permit is issued, I shall mploy persons subject to workman's compensation laws of California." <br />I will caI to /a Gro I Inspection prior to grouting and a final inspection. <br /> <br />it'd/4f <br /> <br />Signed X <br /> <br />Title: Date <br />(Draw Plot Plan on Reverse Side)