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f . Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a �j!i✓J FOR OFFICE USE: APPLICATION k (For Non-Translerable, Revocable, Suspendable) PUMP&WELL r, ENVIRONMENTAL HEALTH PERMIT ;--,(COMPLETE IN TRIPLICATE) WATER QUALITY �xj Application ishereby made tothe San Joaquin Local Health District for apermit toconstruct and/or install the work herein described.This applicatiogris O(1 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 ,217--421 C_/O TT City/Town e f Owner's Name J! D Phone, Ni Address 9 4 TD City 1./N Contractor's Name Oil! tv&-Zy— 74,7License#3370 Business Phone 7 S9 337 Contractor's Address &A Emergency Phone _7457 _3�5' Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL$ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I REPLACEMENT❑ DISTANCE--TO•NEAREST: -Septic Tank, 11 Z Sewer Lines Pit"Privy-- --- - -- Sewage Disposal Field --Cesspool/Seepage Pit �� Other - - Property Linel%-�Private Domestic Well r=-Public Domestic Well INTENDED USE r TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal So ' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 5,4fol—e 61Weed— �J ❑ DISPOSAL ? ❑ OTHER Other Information �� ❑ GEOPHYSICAL Surface Seal Installed By: tiJ PUMP INSTALLATION:-� .." . ..� Contractor_ �/� •LL�GL �7LJLL/�t/G Type of Pump H.P. PUMP REPLACEMENT: A State Work Done t PUMP REPAIR: ,��//' ❑ State Work Done u� DESTRUCTION OF WELL: �" f�G"" Well Diameter Approximate Depth �ADescribe Material and Procedure 1 ^� I hereby cert y that 1 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." r 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." Iwill all fora Gout Inspec'on prior to grouting and a final inspection. _ z -` = Signed X _ Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE!ONLY ; PHASEI ' j Application Accepted By Date Additional Comments: P e 1 Grvut I ection r j _ 19 Ph a ill Fi I Inspection i Inspection 8 � atej st "" Inspection By ` � Date MEW Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I DATE DATE' REMITTED AMOUNT t FEE ). I LESS 4 i PRORATIONi l PLUS E ! i A . PENALTY _ S OTHER = i OTHER 1 Heceived by Date Receipt No. - Permit No. issuance Date Mailed. Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 20119 STOCKTON,CA 95201 1