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.. ,. Applications Will Be Processed When Submitted roper � r APPLICATION FOR OFFICE USE: (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) ZC rn� WATER QUALITY 3 ` �tvX Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliant with San Joaquin County rdin��No. 1862 and the rules and regulations of the San J aquin,-,LocahH�eaith istrict- FA 9 City/Town 1�r�+�- -, • - Exact Site Addresk S h v U �j d— .71 aP_ �{' �' r"��'• Phone Owner's Name City � GA f"O Address 76 i V_v Ih,-LicenseTh+ --?�� Business Phone Contractor's Nam Y Emergency Phone Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� I` TYPE OF WORK (CHECK): NEW WELL 0r DEEPEN 11 RECONDITION 11 DESTRUCTION❑ _ 3 PUMP INSTALLATION WELL CHLORINATION 11 WELL ABANDONMENT El OTHER ❑ ❑ PUMP REPAIR 5 REPLACEMENTS�wer Lines ❑ . Pit Privy DISTANCE TO NEAREST: Septic Tank Cess l/See page Pit Other Sewage Disposal Field f' poopg '� Property Line 'Private Domestic Well Public Domestic Well r L, INTENDED USE TYPE OF WEL � Dia. of Well Excavation 11 INDUSTRIAL ❑ CABLE TOOL 2 pOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC 1:1 DRIVEN Gauge of Casing i ❑ IRRIGATION ;13 GRAVEL PACK Depth of Grout Seal �d ❑ CATHODIC PROTECTION �-OTARY Type of Grout , ba t ❑ DISPOSAL 13 OTHER Other Information ��a'1 Surface Seal Installed 8y: ' ❑ GEOPHYSICAL PUMP INSTALLATION: , t Contractor H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done i f L3 State Work Done PUMP REPAIR: ¢ Well Diameter p Approximate Depth DESTRUCTION OF WELL: s ; Describe Material and Procedure application and that the work will be done in accordance with San Joaquin County .�. I hereby certify that I have prepared this app ordinances, state laws,and rules and regulations of the,San Joaquin Local Health District. Homeowner a licensed agent's signaturein rtifies the such mannerlowing:"I as to becomelfy that in the subject to workman's compensatiionrk flaws of California."r which this nc of is issued, I shall not employ any person + . 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." will call for a Grou for to grouting and a final inspection. ` f Title:, Date: Signed X p - 1 (Draw Plat Plarran Reverse.Side) _ t FOR DEPARTM NT USE ONLY Al PHASE I x O '� 79 Date Application Accepted By Additional Comments: hose Fi at In ection ' hase N Grout Inspection f Dat I Inspection By Date Inspection By r ❑ PER UNIT EI SITE ❑ EACH ❑ January.l &Received By Jan a �E] July REMIT 1 8 Received'By July 31 Fee IS Due: ❑ ANNUALLY i - BILLING REMITTANCE AMOUNT DUE CHECKED I BASE EXPLANATION ,DATE DATE REMITTED - AMOUNT r FEE LESS PRORATION < S PLUS PENALTY OTHER s F:1::: 171 29 tt S . Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - _ 1601 E-HA2ELTON AYE-,P.a•BOK 2009 STOCKTON,C0 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES _ a.