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Applications Will Be Processed When Submitted Propetly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL �.I�JJ ENVIRONMENTAL HEALTH PERMIT. !" (COMPLETE IN TRIPLICATE) WATER QUALITY �1 Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 4862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address /`AA- (7,4 C lee,Cic�/ /3r/dc e- '/,62.4 City/Town J 115 .4.7 Owner's Name - J fIC. 41045 �, cf.�c7 Phone 9144-2 Z a 1 Address /-7-, M2_7 ( City r oc oh f F Contractor's Name r /� S5K cense#RE_ 9/6S Business Phone K916J 37/ -6Z-? Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�- No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property tine Private Domestic Well Public Domestic Well I INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ 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 c' ❑ CATHODIC PROTECTION ROTARY Type of Grout nCee� I❑ DISPOSAL ❑ OTHER Other Information ,+q+ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. r t PUMP REPLACEMENT: ❑ State Work Done A PUMP REPAIR: ❑ State Work Done _ p DESTRUCTION OF WELL: Well Diameter Approximate DeptJ1 �• Describe Material and Procedure_F/�� /�i��J Cc�/9CY�?_�G GyDu 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. 1 Homeowner 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 for which this mit is issued, I shall employ persons subject to workman's compensation laws of California." 1 will call for a Gro pe Ion p to grouting and a final inspection. � � ,� Signed �rtG �"Y I �r Title: r � �l�tCIu�rr Date: (Draw Plot Plan on Reverse Side) V�� f/C!r✓/r�� FOR DEPART NT USE ONLY PHASEI f Application Accepted By Q/ Date l �� Additional Comments: Phase 11 Grout Inspection Phas 11 inal In ection 7&C Inspection By Date Inspection By Date E I' I/&p �✓o o�-, e GG,..L(v� �,� Gam.. %� .� r Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ E CI Jgiary 1 &Receiv R January 31 ❑ J 1 Re a July 3,1 BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DU£ HECKEO DATE DATE REMITTED AMOUNT i FEE [ LESS PRORATION PLUS . PENALTY OTHER I OTHER 0331 9 - )-.q 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.Box 2009 STOCKTON,CA 95201 4