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u Ap 1i- ti4tA p I f��c se W ubmitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION JUL 1 ti 2 6fes( or - ansferable,Revocable;Suspendable) PLUMP&WELL / JULj�NVIRONMENTAL HEALTH PERMIT ! {COMPLETE IN TRIPLICATE f( j;'r l WATER QUALITY , „- -A a �"Pq .00A v F Application is hereby madeto it NIj ' uha�Vgft gthDistrictforapermittoconstructand/or install thework.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 a� f 5� n CitylTown Owner's Name ' °Q L' Phone" „ s Address A �/ City... 5o , Contractor's Name �l �r�rI 't" License#,'l/' 73` {Business Phone �� c Contractor's Address � r _ -"' }` '' "Emergency Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Y Y TYPE OF WORK (CHECK): NEW WELL❑ W-DEEPEN ❑ RECONDITION❑' DESTRUCTIOhf❑ l WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ i REPLACEMENT[] J DISYANCE TO NEAREST: Septic Tank K Sewer Lines Pit Privy ` Sewage Disposal Field Cesspool/Seepage Pit Other �✓ Property.Line • Private Domestic Well Public Domestic Well " INTENDED USE TYPE OF WELL i ❑ INDUSTRIAL 13"CABLE TOOL D--ia.'of Well Excavation ' y� 0 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 ❑ DISPOSAL ❑ OTHER Other information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. 0 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. Horde owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ any person-!n 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 permit is issued, I shall employ persons subject td workman's compensation laws of California." will call for a Grout Inspection prior to groutingand-a.final inspection. ;-T• Signed X r . _ Title: - '. Date: - 1 - (Draw Plot Plan on Reverse Ide) - FOR DEPARTMENT USE ONLY PHASE.I - r Application Accepted By Date - -- Additional Comments: Phase II Grout Inspection f dsq III Final I spection Inspection ByDate Inspection By Feels Due: 11ANNUALLY 11PER UNIT -❑ PER SITE EACH - ❑ January 1 & Re w By January 31 ❑ July 1 8 Received By July 31 REMIT BILLING ..REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED gAMOUNT � FEE "� � t LESS PRORATION PLUS PENALTY OTHER ti OTHER i Received by - Date- Receipt No. Permit No. Issuan a Date Mailed Delivered: — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2909 STOCKTON,CA 95201 F ..