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d-s f_ 11p kfIAidtsWill Be Processed wtj�hAbmlttedProperly Gompreiea. oc�N•� •�--•�•• -� y S APPLICATION J- =OffICE � 190B3 +>(For Non-Transferable,'Revocable, Suspendable) PUMP&W>=L� , � dY4 �ONMENTAL HEALTH PERMIT Air -�4��'�` ;_ I GT WATER QuauTr . ;,,,. .2�I o -0 + (COMPLETE IN TRIPLICATE)'^ -` '»,rtr 'n'` Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or Install the work her described.This application is made incompliance with San Joaquin County Or inance No. 1862 and the rules and regulations of the San aaquin Local Health District- L• ep Iiii, City/Town ' Exact•Site Address ULC c I r , " Phone ' '• Owner's Name f- �•. City- Address ity Address w,- dLicensj Business Phone ` - e# Contractor's Name $ :.I I 'Emergency Phone ` Contractor's Address1 �/ _ Is Certificate of Workman's Compensation Insurance o Ile i SJLHD? Yes No NEW WELL C3 [3 ❑ RECONDITION❑ DESTRUCTION❑ TYPE OF WORK (CHECK): ❑ PUMP REPAIR _.: rt F, , eoerrnnAlnaGAIT_ OTHER [3 PUMP INSTALLATION 4 tiu Sewage Disposal Field Cesspoo eepag l; Property Line Private Domestic Well Public Domestic Well , I INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 4 11 CABLE TO Dia. of Well Excavation r ❑ DOMESTIC/PRIVATE El DRILLED of Well Casing DRILLED t" 13 DRIVEN Gauge of Casing t�r=, ❑ DOMESTIC/PUBLIC Depth of Grout Seal `� ❑ IRRIGATION ❑,_GRAVEL PACK R 11CATHODIC.PROTECTION ROTARY Type of Grout _ ❑ OTHER Other Information S , [I DISPOSAL s , Surface Seal Installed By: ❑ GEOPHYSICAL T � I PUMP INSTALLATION: Contractor Type of Pump P ❑. State Work Done UMP REPLACEMENT: '' •'`Gtrt'''�' PUMP REPAIR: State Work Don DESTRUCTION OF WELL: Well Diameter Approximate Depth ''''Describe Material and Procedure accordance with San Joaquin County r done in � - F I hereby certify that I have prepared this application and that the work will be ordinances, state laws, and—r.ules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: oll as ngbecomelfy thj that to oin the erkman'sncompensationce of the work f laws of California."or which this s� is issued, 1 shall not employ any person in such Contractor's hiring or sub signature certifies the following:"I certify that in the performance of the work for which this I permit is issued, I shall employ persons subject to workrilan's compensation laws of California." I will call�Iora �nsp�ecprior to grouting•and a final inspect• Date: �� Title:Signed X - , o r j (Draw Plot Plan on Reverse Side) Y _. •;�.: FOR DEPARTME •~,t. NT USE ONLY PHASE I G� 1 Date "? la — Application Accepted By S �A Additional Comments: Phase III Final Inspection r Phase li Grout Inspection Inspection By —'� Date Inspection By Date k +-• REMIT Fee IS Due: ANNUALLY ❑ PER UNIT' El SkTE EACH ❑ January 1 &Received'Ry January 31 ❑'July t &Received BY July 31 ' ..BILLING _,REMITTANCE $ AMOUNT DUE CHECKED BASE"-' F- —EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS r PRORATION PLUS PENALTY; OTHER r y - OTHER y 4I�a ice Dale :-- Mailed - Delivered Receipt No. — - Permit No. - � Received by � Date 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALTH PERMIRrICE5 ��.-.