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." Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION {` (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 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•Joa uin-Gount Ordinance No.71862-and the.rules and-regulations of-the-San-Joaquin-Local-Health-District. Exact Site Address - _`.��r2 C T City/Town ,D C Owner's Name - s a l,.f Phone Address b • % City—_.5 G�/'�7o rtl� Contractor's Name Ll,'V JV&& 5174- PIMP ull iLicense #�'& �� f Business Phone Contractor's Address//.?14 Al, 12,021) 3 -,r_A-ZF Emergency Phone $,4rr3Z Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes c No ►,/f�� TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V 11 WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 13PUMP TALLATION16 PUMP REPAIR❑ REPLACEMENT❑ t� DISTANCE TO NEAREST: Septic Tanks Sewer Lines Pit Privy �J Sewage Disposal Field Cesspool/Seepage Pit Other 1- Property Line�66��' Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation E(DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout t ❑ DISPOSAL ❑ OTHER Other Information h 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor /Y e-7- fi160✓dam. U Type of Pump- A,ich U 1.P.!' PUMP REPLACEMENT: Jd State Work Done t Pi'5 4 4_4-c57�6 C-o'.9 re 14, rioc a5- -PC/III 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit `r is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's ring r sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is is ed, hal em loy pe sons subject to workman's compensation laws of California." I will Cali G out Inspe ion p or outing and a final inspection. p Signed X Title: Date: -Piot Plan on Reverse Side) } FOR DEPARTMENT USE ONLY PHASEI Application Accepted By -- -_ Date Additional Comments: Phase II Grout Inspection ase I al Ins tion Inspection By Date Inspection Byte Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 { REMIT E BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMDUNT DUE CHECKED i AMOUNT y/�I FEE LESS PRORATION PLUS PENALTY p Cin iiCj v (u. OTHER OTHER Received by Date ,. Receipt No Permit No. I Issuanciii Datb Mailed Delivered APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009. -STOCKTON,CA 95201 I