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"��.. Applications Will Be Processed WhenSubmitted ProperlyCompleted. seSure io sign ineRppncalnon. „Fyr3'R OFFICE USE: APPLICATION �1r (For Non-Transferable, Revocable,Suspendable) df� H a, f _ PUMP&WELL � ENVIRONMENTAL HEALTH PERMIT ,y i (COMPLETE IN TRIPLICATE) WATER QUALITY v Application is hereby madeto 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 Joaquin Local Health District. y Exact Site Address _ � N+ DUST/�[L �` City/Town o0 4 Owner's Name /46W Phone 3 �� Address 9•:8 -3l0 /S , 72r1ST/,</ City saa� Contractor's Name 61650It li_&_L4-_ _nJ2_tUWA6C License#337+x$2 Business Phone 7 Sr! 3 77 Contractor's Address 3 n -. Emergency Phone -7 3� ] Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo TYPE OF WORK (CHECK): NEW WELL DEEPEN 1:1 RECONDITI ONE DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sd Sewer Lines �d Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well a ._ Public Domestic Well INTENDED USE TYPE OF WELL e( ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ""❑ DRILLED Dia. of Well Casing T �� fdIE�STIP ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �- ❑ CAT _D1G Pfi CTION ❑ ROTARY Type of Grout a DISPOSAL ❑ OTHER Other Information t ❑ GEOPHYSICAL —"Turfac Seal Installed By: PUMP INSTALLATION: ContractorPD ,k a' Type of Pump P. PUMP REPLACEMENT: ❑ State Work Done ' PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure s 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 li 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i permit is issued. I shall employ persons subject to workman's compensation laws of California." I will all for a Grout Inspection rior t grouting and a final inspection. �y Signed X - - Title: Date: f�^ Z"a (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY` PHASE Application Accepted By Date Additional Comments: Phase II rut spection Pha a II in Inspect) In r Inspection By Date Inspection By Da e j Fee IS Due: ❑ 'ANNUALLY ❑ PER UNIT: ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. - LJ 1 1 &Received By July 31 + REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED , DATE DATE REMITTED AMOUNT FEE LESS ' PRORATION PLUS PENALTY OTHER OTHER - f 3�0o ft a 7 Received by Date Receipt No. Permit No, Iss ante Date Mailed Delivered APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E:HAZELTON AVE.,P.D.Box 2009 -STOCKTON,CA 95201