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Applications*1II Be Processed When Submitted ProperlyCompleted. BeSureTosign TneApprlcanon. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) , PUMP&WELL i I ENVIRONMENTAL HEALTH PERMIT ( 1 (S"~?_ Sct�a �. WATER QUALITY ,_ �7 COMPLETE IN TRIPLICATE (p S_, .J• I /�. Application is hereby made to the SanUoaquin Local Health District&01111 permit to construct and/or install the work herein described.This application is made in compliance w' n J in Co Ordinance No. 1852 and the rules a regulations of t n Joaquin Local H alth District. Exact Site Address — ° /✓ b' T� ,w1 )Nrc. Z'o 1 q:, Owner's Name I�' >D Phone Address City � 7 Contractor' Nam L / MCf Livens – Business Phone —LS �g y Contractor's Addresses � F � �� Emergency Phone � q y Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q } TYPE OF WORK (CHECK): NEWS WELL Et'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION ®—PUMP REPAIR❑ k REPLACEMENT❑ I� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewalge Disposal Field Cesspool/Seepage Pit eVC3"r--�_ Other Property Line Private Domestic Wel! Public Domestic Well INTENDED USE TYPE OF WELL �1 ❑ INDUSTRIAL ' ❑ CABLE TOOL Dia. of Well Excavation y �r ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing { ,M IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Z ROTARY Type of Grout 13 DISPOSAL 11 OTHER Other Information 11 GEOPHYSICAL Surface Seal Installed By: ; PUMP INSTALLATION: Contractor Z4z y a 3 Type of Pump � �/� t:�r H.P. PUMP REPLACEMENT: ❑ State Work Done t PUMP REPAIR: ❑ State Work Done` _ t 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 license d1agent'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 for which this permit is issued, I shall mpl ersons subject to workman's compensation laws of California." ill call for a Grout ric pr r to gr uting and a final inspection. . Signed X Title: _ ter v — 7 Date: �I (Draw Plot Plan on Reverse Side) . I FOR DEPARTMENT USE ONLY �•CJ Date�--`—'.� " Application Accepted By I Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By I� Date Inspection By �` rte`'"`"/(l'/�/1� Date _2'�l Fee Is Due: ❑ ANNUALLY a�.❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 REMIT BiLLING REMITTANCE - AMOUNT DUE CHECKED,. I EI BAS �j EXPLANATION DATE DATE REMITTED �I. AMOUNT FEE aalF LESS PRORATION SII 1 ` PLUS PENALTY OTHER 4 OTHER 1� Received b .Date: Receipt o, Permit No. Issuance Date Mailed Delivered - - ■2009 .STOCKTON,CA 95201 ERMITlSERVICES, - 1601 E.HAZELTON AVE.,P.O.80 , - APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH P ,.� _ F :a fff � { 6.