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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION r' (For Non-Transferable,.4evocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT I (COMPLETE IN TRIPLICATE)Lrg an$. 9' , WATER QUALITY !J ZU� ��ECw OL Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/or install the work herein described'.This application is ` made in compliance wjtJ1 an Joaquin County Ordinance 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town / - � Owner's Name f ! ' 1 Phone Address Mdf i . ^_" ' Cit i l Contractor's Name 0,11n 1111Aea License#1?c,?1IU Business Phone }S.til -':Z �b A: Contractor's Address Emergency Phone y" Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k No TYPE OF WORK (CHECK): NEW WELLY_ DEEPEN 11 RECONDITION DESTRUCTION❑ �Q WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION.❑ PUMP REPAIR❑ �_ REPLACEMENT❑ { 1 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy O Sewage Disposal Fiejd l�/�D I Cessp000l/$eepage Pit Other�e1 ` Property Line/0 :t Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ,CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC O'DRIVEN Gauge of Casing ZQ a�__._&/, J,6r& � g IRRIGATION ; ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Z� 0 DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: i.2 AJAr1h PUMP INSTALLATION: I Contractor W ` Type of Pump W P p PUMP REPLACEMENT: State-Work Done PUMP REPAIR: ❑ State Work Done t {� DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure _ i k 1 hereby certify that 1 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 4 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 r permit is issued, I shall employ pers s subject to workman's compensation laws of California." - I will Cal or a Grt In,4pecti p r to grouting and a final inspection. f { Signed X- Title: Date: ,2/0r_ { (Draw Plot Plan on Revel's Side) 4 µ ff FOR DEPARTMENT USE ONLY k - PHASE I i 1'2 4 Application Accepted By • + r 1J Date " Additional Comments:d E P 4 Phase&I rGrout Inspection ` p .. hose III Final Inspection Inspection By -.-dam pate ; -- Inspection By i Dater Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Heceived By July 31 F REMIT f• BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED GATE GATE REMITTED AMOUNT FEE a LESS s PRORATION PLUS PENALTY x OTHER OFHER Received by Date Receipt No Permit No. - I suanee Date .Mailed ,Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201