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Applications Will fielProc(essed 1�ilhei;%dbmltted Properly Completed. Be ure To Sign The Ap lication. II 1 ?--A spa! L�'C-;TION2 }} ! FOR OFFICE USE: . L+.1 i d a l� ` (Folmar Non-Transferltblej Revocable,Suspendable) PUMP&WELL '- � 1 WVIR�NMENTAL HEALTH'PERMIT r (COMPLETE IN TRIPLICATE) �uq,;� If ;T.+��v� WATER QUALITY' ' aUd�lI;JRit s Application is hereby made to the San Joag 6jL!tical#Wa'� Distfitoa,permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Orrdinance�Nb"j` th $62=aand' e rules and regulations of the San Joaquin Local Health District. + . Exact Site Address0 y '� City/Town Owner's`Na_me �. rl = s.n t L:^ t Phone ��.�' �'P�.� Address • �Ar—f 2� z. City. Contractor's Name License#r 1 d X313 TBusiness Phone Contractor's Address Emergency Phone DID Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1. TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑/ WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 11ltd PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ l!� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line.Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL USYRIAL 11CABLE TOOL Dia. of Well Excavation F DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC'; ` ❑ DRIVEN Gauge of Casing IR ❑ RIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL. ❑ OTHER I Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Ty e of Pump H.P. PUMP REPLACEMENT: State Work Done �v /?� »�I�. /�<.r - /� ec� iv/�,dei G-• PUMP REPAIR: ❑ State Work Done r- 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." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X /L4,,&, Q.., Title: ,.. +.,/ 3 Date: f - �2 9 ��d - i (Draw Plot Plan on'Reverse Si e) FOR DEPARTMENT USE ONLY / PHASE I Application Accepted By /� � f Date ` O Additional Comments: Phase Ii Grout Inspection e It Inal Inspection „r Inspection By Date Inspection B _ Date i ffF Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 eceive By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT ` BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT sFEE ? 00 LESS V. PRORATION PLUS PENALTY OTHER I y OTHER - .Received by ,.r DaI4 Receipt No. - -Permit No. -- Isduance D e - Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA"95201