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Applications Will Be Processed When Submitted Properly Completed. Be SureT ign-,Th�%A ' tion. - FOR OFFICE USE: - .�� APPLICATION �S ' "N (For Non-Transferable, Revocable, Jejb`l!A MP&WELL ENVIRONMENTAL HEALTT (COMPLETE IN TRIPLICATE) WATER QUALITY APR 20 1981 Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or ins l�# wTtc�tY{e['dfi� Il cribed.This applicat+on is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulatl6YlS°°f tle�a79}RtyJ..Jca1 Health District. Exact Site Address 5S CW176" n .� Owner's Name Phone Address Cityn/ to r Contractor's Name :e cense# Business Phone �� 1 Ea Contractor's Address mergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ R WELL CHLORINAT 13WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 67�PUMP REPAIR❑` REPLACEMENT ' �} DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well ❑lIIN ENDED USE TYPE OF WELL USTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/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 Installed By: PUMP INSTALLATION: Contractor T e of Pump H.P. PUMP REPLACEMENT: State Work Done &a I, PUMP REPAIR: ❑ State Work Done C DESTRUCTION OF WELL: Well Diameter Approximate Depth ' Describe Material and Procedure n 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. 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." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X u Title: `TTj ao2!A,,gA1 Date: (D(aw Plot Plan on Reverse Side) - — FOR DEPARTMENT USE ONLY PHASEI: *1 Application Accepted By Date �`' Additional Comments: Phase II Grout Inspection P ase III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ FACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION PATE PATE REMhTTED AMOUNT DUE CHECKED C UNT dO �p a FEE } `4 S LESS PRORATION PLUS y PENALTY II OTHER OTHER I Received by Date Receipt No. Permit No "Nuance Da et M2filed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009. STOCKTON,CA 95201 .I - A.