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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOA OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) �1 ENVIRONMENTAL HEALTH PERMIT PUMP&1WELL 1 (COMPLETE IN TRIPLICATE) WATER QUALITY A/62 0 fur 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. 1862 and the rules and regulations of the San J�j aquin Local Health District. Exact Site Address ,,i -� J" � Co ✓ A?d _ City/Town f7` IYi Owner's Na a LO+� �►� Phone Address . !- City Contractor's Name f E icense#,3812.2 Business Phone + Contractor's Address U IF a rim Emergency Phone _5�9Ii�t GI: 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❑ f f� //'��,, . q + DISTANCE TO NEAREST: Septic Tank ©a'7"f"' Sewer Lines .��'I�'�" Pit Privy Sewage Disposa h+G �. Cess�po7ool/Seepage Pit D ed� Other ii ti '� Property Lin `r Private Domestic Well A Q -IP Public Domestic Well IJ© *40 42 INTENDED USE TYPE OF WELL ❑ INDUSTRIALABLE TOOL 11;2 !� Dia. of Well Excavation �OMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing rf ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a. G• ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout e r" aJd�' ❑ DISPOSAL ❑ OTHER Other Information L1 _ GEOPHYSICAL ' AD Surface Seal Installed B � ( Q 11 PUMP INSTALLATION: Contractor o Vi l+ � � �• Type of Pump 640 C7 H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth + %� Describe Material and Procedure !¢ , 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. . 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this' permit is issued, I shall employ persons subject to workman's compensation laws of California." ' call for a Grout Inspection prior to grouting-and a final-inspection. Signed X Title: ��--� � Date: 1— - (Draw Plot Plan on Reverse Side)` _ J FOR DE ARTMENT USE ONLY PHASE ] Application Accepted By 7 Date Additional Comments: - ' - r# Phase If Grout Inspection 4 YphTMse III Final Ins ection Inspection By Date inspection By ate Fee Is Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R'ece'ived-ay-,January 31 ❑ July 1 &Received By J61y,31 BILLING REMITTANCE $a t REMIT BASEEXPLANATION DATE DATE - REMITTED AMOUNT DUE CHEC�EbAMOU - FEE f LESS . �& PRORATION �- PENALTY OTHER-�-_. .�.,.-. .- .«. .- - .-.e-,,:r- �a- -• - - -- ' - - i OTHER 7 _ -y _7 ,w Received by Date Receipt No. Permit No. Issuance Date -shed Delivered APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .