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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transierable, Revocable, Suspendable)NA ! ENVIRONMENTAL HEALTH PERMIT PUMP & WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madetothe 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)oaquin Local Health District, Exact Site Address 471-LIr77T )E>04- a 43A>1DGL- okeelp 2D)9 C e;&� City/Town M% a Z0CkfQ1?D Owner's Name S- 7- C001V7-yPUBI/C Wa)PhV DEAT Phone 9frZ -22 R/ Address lelo E. /-1AZE.L% D/y City' ..S TOG/ -22,V 0 Contractor's Name 1Vi®�� T/�$t`/'P C-EO,LCx5/,$ License #/ IF 916S Business Ph Contractor's Address –514CRA1VJely7 " Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes JIG No TYPE OF WORK (CHECK): NEW WELL U DEEPEN ❑ RECONDITION ❑ DESTRUCTION X WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR ❑ REPLACEMENT ❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ DOMESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL X GEOPHYSICAL PUMP INSTALLATION: PUMP REPLACEMENT: PUMP REPAIR: DESTRUCTION OF WELL: ❑ CABLE TOOL ❑ DRILLED Eff DRIVEN ❑ GRAVEL PACK ® ROTARY ❑ OTHER Contractor Type of Pump ❑ State Work Done ❑ State Work Done .. Well Diameter Describe Material and Procedure Dia. of Well Excavation Dia. of Well Casing Gauge of Casing Depth of Grout Seal Type of Grout Other Information Surface Seal Installed By: 3" H.P. Other Approximate Depth S"D F 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. Homeowner 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 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I I I 11 for rout Ins ection riot to grouting and a final inspection. 7 Signed X Title: –S r GL. Date: "� ~2 (Draw Plot Plan on Reverse Side) L—Zecerveu uy Date Receipt No. Permit No. - +ssuan�e Date Maned Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.D. Box 2009 STOCKTON, CA 95201 FOR DE TME USE ONLY PHASE , Application Accepted By • Date .2n,2— Additional Comments: ase 11 Gro In ction hese I 1 F nal Inspection Inspection By nspection ( � pie Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE EACH January 1 & eceived By January 31 Q July 1 & Recei tl y Jul BASE EXPLANATION BILLING PATE REMITTANCE $ AMOUNT DUE REMIT CHECKED DATE REMITTED AMOUNT FEE -- LESS PRORATION PLUS PENALTY OTHER OTHER X33— L—Zecerveu uy Date Receipt No. Permit No. - +ssuan�e Date Maned Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.D. Box 2009 STOCKTON, CA 95201