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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,FOR oVICE USE: APPLICATION $. (For Non-Transferable, Revocable, Suspendable) I' - PUMP&WELL ENVIRONMENTAL HEALTH PERMIT iWATER QUALITY 0 r -- 040-- l g (COMPLETE IN TRIPLICATE) 'f�''205—Le 7 -_d X15: PFJ Q iL1 = 3 Appiication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is I 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 E' OD d I ��Oi��c� DM�V1s Rcl <5"-City/Town ©p� r I Owner's Name _ L At MAN Z 159-ND Phone Address Y r City 4AD1 Contractor's NameLicense#3S'_'7313 Business Phone 9SRgFPg'/7 I Contractor's Address bb ' ST' Emergency Phone oc� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesy No �y TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENTZI DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE r TYPE OF WELL !. j ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C 1 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor slooc,15 J oos _ Type of_Pump H,P, �T PUMP REPLACEMENT: ❑ St .Y ate Work Done " u PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: Well Diameterg„ - Approximate Depth Describe Material and Procedure F . ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County F ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. F Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t , is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." p, Contractor's hiring or sub-contracting signature certifies the following:'9 certify that in the performance of the work for which this O� permit is issued, I shall employ persons subject to workman's compensation laws of California." f , I will call for a Grou1'Inspection prior to grouting and a final inspection. E � Signed X �d-Q. Title: dirt.e[�.P�L_ Date: U (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Al1 Application Accepted By - -- Date p Additional Comments:" Phise II Grout Inspection Ph a a III Final Inspection Inspection By Date Inspection Bye I �eDate v Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE - -$ - AMOUNT DUE CHECKED • DATE DATE REMITTED AMOUNT FEE 44S LESS PRORATION ' PLUS PENALTY 4 OTHER OTHER -A, - -- Received by Date Receipt No. Permit No. ssuan a Date Mailed - Delivered .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 9520111