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Applications Will Be Processed When Submitted Properly Completes Sure To Sign The Applicatilo FOR o FIC E usE: APPLICATION NOV 26 1979 r� A (For Non-Transferable, Revocable, Suspendable) PUMP&WALL 1 i ENVIRONMENTAL HEALTH PERMSAN JOAQUIN LOCAL 00 (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT l" 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 6. made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District, A Exact Site Address 1-0 1911.0 V=kgJ1J_ ,al City/Town ha 607 Fr,'s ee A.Itie ��r Owner's Name Phone Address +kl ' City_ T?_c - Contractor's Name 1 Ca- License# Business Phone X,7 1.2 Contractor's Address �� Emergency�Ph/one Y,--7 g�2 i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes lC No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1 a d r Sewer Lines ja 1 Pit Privy Sewage Disposal Field 100 f Cesspool/Seepage Pit Other Property Line 10t Private Domestic Well -__' Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing fQ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t o ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal f Q ElCATHODIC PROTECTION 6Y ROTARY Type of Grout /pPYJ V ❑ DISPOSAL ❑ OTHER Other Information .1,106 hy ❑ GEOPHYSICAL 4 Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: 11 State Work Done PUMP REPAIR: "'�I ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure l 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. Homeowner or licensed agent's signature certifies the iollowing:"I certify that in the performanceof the work for which this permit x is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1 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. p Signed X Title: � bate: (Draw Plot Plan on Reverse Side) 4 s F, DEP TMENT USE ONLY PHASF I Application Accepted By Date 7 Additional Comments: Phase_II Grout Inspection + � Phase I11 Final Inspection Inspection By Date Inspection By � lfba Dater 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 EXPLANATION DATE DATE AMOUNT DUE CHECKED REMITTED JAMOUNT FEE " LESS PRORATION PLUS PENALTY OTHER OTHER 7-5 t —7 't--%dip S 11 /'/l Received by Date Receipt No. Permit No. issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952