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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application'. FOR OFFICE USE: APPLICATION al r (For Non-Transferable, Revocable Suspendable) PUMP&WELL fI X59 Z /`1R ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) _ 0�T� R 6f WATER QUALITY Application is hereby madetothe San Joaquin Local Health Disfrictfora permitto construct and/or install thework herein described.This application is made in compliance wjth,�� tayu a C qty Oar in nce�la X862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 4s{i/�� [��s[�! mac _�i, —-- e City/Town Owner's Name _Jofpa�/-�' T�Gc�oa Phone 3 Address 1951912 /y ezz11077 P-0 City Contractor's Name !0-5004 WAM=='DRALdAt6 License#13,3799,r Business Phone ;?12g=5 Contractor's Address _P060jf 3 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? yes.�� No TYPE OF WORK (CHECK): XNEW WELL DEEPEN 11 RECONDITION u DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION ❑ PUMP REPAIR© REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 49e I-Sewer Lines Ip Pit Privy r . Sewage Disposal Field Cesspool/Seepage Pit Other Property Lined Private Domestic Well 4%dg,�2 Public Domestic Well INTENDEDUSE TYPE OF WELL INDUSTRIAL CABLE TOOL Dia. of Well Excavation / 1f ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing g 5rDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /4 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ;04,e- ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: FaA4 XW537i4dA!W—. ! PUMP INSTALLATION: Contractor S<../1 77, Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ~' r 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 fallowing:"I certify that in the performanceof 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." I will 11 fora Gr u1 Inspection prior to grouting and a final inspection. Signed X Title: Dater (Draw Plot Plan on Reverse Side) FOR DE ARTMENT USE ONLY PHASE Application Accepted By Date I -7 Additional Comments: Phase II Grout Inspection Ph 11 Fin Inspection Inspection By Dates. Z' Inspection By liv ��3' � Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received-By July 31 REMIT BILLING REMITTANCE $ BASE EXP1_ANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER -7c'l i�c71 ��75� ? � Received by Date Receipt No. Permit No. _ Issuance ate Maile De Ivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' f