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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. '�°-- FOR OFFICE USE: APPLICATION v (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY f Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is i ` made in compliance with San Joaquin County Ordinance No. 1862 and the r sand regulations of the San Joaquin Local Hea�lt�l-, District. Exact Site Address 10 �� City/Town S�eJcrV� O Owner's Name .vf o w�� `�� C��E�'�� Phone �t Address — r3 1►� ?f- Contractor's ECity ��T� �1 'i �a— Contractor's Name VV �%� License# V._ Business Phone i Contractor's Address ZrD�.. C �+►�� Emergency Phone 11.E j Is Certificate of Workman's Compensation In� ura�n � � sn File With SJLHD? Yes__ — No r. TYPE OF WORK (CHECK): NEW WELLL61, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION-11 WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION 11PUMP REPAIR REPLACEMENT❑ 1 ` DISTANCE TO NEAREST: Septic Tank �� Sewer Lines ?r� Pit Privy Sewage Disposal Field LCesspool/Seepage Pit Other Property Line—Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 11 IIy8L75TRIAL `�❑-GABLE TGOL- Dia.--of-Well Excavation w--p a �/ & { DOMESTIC/PRIVATE ❑ DRpi ILLED a. of Well Casing \ ❑ DOMESTIC/PUBLIC - f ❑ DRIVEN Gauge of Casing `Y a ❑ IRRIGATION `, ❑ EL PACK Depth of Grout Seal �8 ❑ CATHODIC.PROTECTION t ROTARY Type of Grout 1:1 DISPOSAL r ' '` ❑ OTHER Other Information `;. - ❑ GEOPHYSICAL' . r= ( W Surface Seal Installed By: PUMP INSTALLATION: € Contractor ' Type of Pump H.P. F ` ❑ State Work Done PUMP REPLACEMENT: ..... PUMP REPAIR: ❑ State Work Done r "'" �� DESTRUCTION OF WELL: 6 Well Diameter A pproximate Depth ' n a Describe Material and Procedure t I hereby certify that I have prepared this application and that the work will be done in accordance with San7oaquin County ordinances, state lawsr and rules and regulations of the-San Joaquin Local Health District. T , Home owner or licensed agent's signature certifes he following:"I certify that in the performance of the.work forwhich 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 peftit is issued, I shall employ persons subject to workman's compensation laws of California." i I A&all for a t In ion pr r to grouting and a final inspection. 14 �+ Signed X - s Title: r7C�_ r> � �� :—> Date'} Fri L< (Draw Plot Plan on Reverse Side) % i ` FOR DEPARTMENT USE ONLY ` PHASE I = "� Application Accepted By Dat = } 4 Additional Comments: `�" - Ph se III Final Phase II Grout Inspection- Inspection Inspection By ate"��0 inspection By Date Fee Is Due: C1 ANNUALLY ❑ PER UNIT El PER SITE'S (�-EACH, [I January 1 &Received By January 31 ❑ July 1 8 Received By Juhy 31 REMIT &-- -•u�.� .BILLING JREMITTANCE-- ^--�.•. $ AMOUNT DUE CHECKED BASE EXPLANATION ppTE .w,,,pAl�Er REAAITTED,_, AMOUNT FEE F LESS _- PRORATION PLUS PENALTY OTHER F OTHER �- —A ��Y-rte Received by Date Receipt No, Permit No. Issuance Date _ Mailed Delivered `\ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 ,