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Applications Will Be Processed WhenSubmittedProperlyCompleted. Be SureToSign TheApplication. FOR OFFICE U-5E. APPLICATION r (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 apillication 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 nn 1311.2 /V: h'194/¢�g City/Town 1-6-04V Name C 11141 P-4i _ Phon� a?6_4VW? Address -Pa Sax zoo City? �7"Iylg 96-647 Contractor's Name d/0.+[--1&d7L T>i�/LL1�Ca License#3370—J Z Business Phone 337 Contractor's Address?04x 15 eAe"&Aii 5 Emergency Phone _ 76-9^ 34- Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X— No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ [� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 111"' PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank //Q Sewer Lines Pit Privy Sewage Disposal Field & Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL © INDUSTRIAL ]9 CABLE TOOL Dia. of Well Excavation for DOMESTIC/PRIVATE 1:1 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /d 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 5i"e- CE.:r.��r✓7 Ca�u� 0 DISPOSAL ❑ OTHER Other Information 0 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump 1 i iiiH.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. Home owner 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 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 to workman's compensation laws of California." 1 will call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: _ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE lication Ac ed By Date Additional Comments: as I Grout Inspection '70Qagi II Final Inspection bQ Inspection By Date it `�1 Inspection By Date R v Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED /3"' � 0 � CHECKED AMOUNT FEE '1 A LE55 ��) PRORATION ✓�1 l, (I PLUS PENAI OTHER OTHER Received by Date Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201