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y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. WR OFFICE USE: - APPLICATION ' .-- - (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT' (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San oaquin County Ordinance No. 1862 and the rules and regulations of the San Jo uin Local Health District. Exact Site Address City/Town i7CIkT� Owner's Name Phone Za Address City Q K Contractor's Name �.L C License# V1 �� Business hone Contractor's Address Emergency Phone 111 Is Certificate of Workman's Compensation lnsura on File With SJLHD? Yes No U3 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank zSt Sewer Lines Pit Privy M Sewage Disposal Field Cesspool/Seepage Pit Other Property tine Private Domestic Well Public Domestic Well INT D USE TYPE OF WELL 0—. `* ❑ USTRIAL .❑ CABLE TOOL Dia. of Well Excavation Z+ I DOMESTIC/PRIVATE 11 DRILLED Dia,ofaWell,Casing _ _❑~DOMESTIC%PUBLIC��' ❑DRIVE Gauge at using IZ ❑ IRRIGATION ❑ EL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout �W i ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor d� } Type of Pump ``- ' H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter �' s Approximate Depth Describe Material and Procedure ` 1 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 anis regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework forwhichthis 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 for which this ermit is issued, I shall employ persons subject to workman's compensation laws of California." wil all f r a r ut In e I n for to grouting and a final inspciion p Signed X Title: W�y` 1�- 1 Date: D J (Draw Plot Plan $n Rev sre a Side) B t FOR EPART_ENT UtE ONLY f PHASE f Application Accepted By }. Date Additional Comments: , Phase 11 Grout Inspection Final Inspection��i/ Inspection By Date Inspection By� Date /6 Fee Is Due' ❑ ANNUALLY ❑ PER UNIT. PER SITE ❑ EACH ❑ January 1 &Recei4d'By_:January 31_ ,�d,-July 1 &_Received By July 31 -�-Al ,"F{5 REMIT BASE EXPLANATION BILLING REMITTANCES AMOUNT DUE CHECKED i DATE DATr #"REMITTED AMOUNT FEE _ y3 LESS O PRORATION - PLUS ecuid p.a tr114l<'2 l..j ff-lar. PENALTY v (Va T 1 0)R OTHER• t 2 ,Q :�lb� Wc. ►LC t.rt} j 2.3 U� �vt 3 OTHER �- Received by Data _ Receipt No: Permit No I Issuande Date .Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,.- -. •...o .a.�..,.. _ - -v , _fir' .-�A