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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. " . ., p Fors OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) k' PUMP.&WELL ENVIRONMENTAL- HEALTH PERMIT (COMPLETE IN-TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Lbcal 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. 1862 and the rules and regulations of the San Joaquin Local Health District. ` ;Exact Site Address e9145_6 Al, Ce-�ME7I r"5 F TSD City/Town j Owner's Name 7"b L Phone 757- 3.50-Ze Address � Y City G�'GI 'E/VTS , C�• . Contractor's Name <211 #aSOA.r bt,=&—W-14L"A-- License#Mt704Z-Business PhoneS77 Contractor's Address P50)L j CSW&5iV 7::S Emergency Phone�,=- Is Certificate of Workman's Compensation Insurance on File.With SJLHD? . Yes ZC � No ad V� TYPE OF WORK (CHECK): NEW WELL DEEPEN EI -_RECONDITION 11 .DESTRUCTION❑ o WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ C f DISTANCE TO NEAREST: Septic Tank oe Sewer Lines .2,604!P oe _ Pit Privy +� Sewage Disposal Field, Cesspool/Seepage Pit Other Property Line;9632 Private Domestic Well 3tl9tV Public Domestic Well P INTENDED USE TYPE OF WELL. ❑ INDUSTRIAL CABLE:TOOL Dia. of Well Excavation �Z-ii /c/,e5T SOS A DOMESTIC/PRIVATE ❑•DRILLED .4. Dia. of Well Casing ❑ DOMESTIC/PUBLIC �+� ❑ DRIVEN Gauge of CasingZX fQ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seals r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7-- DISPOSAL DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: ,,. Contractor /�3 Type of Pump a N.P._ '7 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL: Well Diameter Approximate_Depth Describe Material and Procedure 1 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 whAe is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the workpermit is issued, I shall employ persons subject to workman's compensation laws of California." I wi call fora Gr ut Inspection prior to grouting and a'final inspection.Signed XTitle: + Date: '(Draw Plot Plan on Reverse.Side) FOR DEPARTMENT USE ONLY - � PHASE I . Application Accepted By�!�� Q �� X Date I / Additional Comments __ _ se II Grout Inspection a _ Phase 1 1 al Ins ection r, I Inspection B �at� Inspection By ate 13 h CD--? Fee Is Dile: ❑ ANNUALLY -❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. Cl July 1 &Received$y July 31 REMIT BILLING REMITTANCE $ ' BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED —� � AMOUNT I FEE LESS PRORATION r °` PLUS PENALTY OTHER _mss.-� t'".''.., -,;f•.. i OTHER l �j6�) 41 _ Received by Date- Receipt No Permit No 'I suanc Date Mailed Delivered AP RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 - '