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Applications Wi l Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. `R OFF!CEVSE: APPLICATION ( 1 (For Non-Transferable, Revocable,Suspendable) r PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) !!! WATER QUALITY Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance w th San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address C.*%9GV4Y i- C. -City/Town 0-t0 61 aftl ow; Owner's Name # 19 Phone "L_"{0_! Address 1 City L0061>BRL'D6F Contractor's Name W ( 4 L saulp License# 371 S46 Business Phone ults7l+' M7 - Contractor's Address %A C CAAMIL WIW Emergency Phone _ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 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 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL QiNDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOM'E'STIC/PRIVATE ❑ DRILLED Dia. of Well Casing 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION 13 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL J Surface Seal Installed By: PUMP INSTALLATION: Contractor C�MkRYC. wE.��+ '� t�61Pi'lEl►�1 '"� .w Type of Pump H.P. 40 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done — DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material"and Procedure ~ a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couniy ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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 bel;ome_subjectto w<ork_man:.,,compensation laws of California." Co tractor's hiring or sub-contracting signature certifies the following:"I certify that in the per1formance of the work for which this pe it is issued, I shall employ persons subject to workman's compensation laws of Califorlia." I w all for r t In n pr' r to grouting a+fd a final ma(pection. Signed X Tltle Date:10 (Draw Plot Plan on averse Side) OR DEP RTMENT-USE ONLY PHASE 1, Application Accepted By -{� � Date Addition24'Com»ieTlts Phase II Grout Inspection Phise III Final Inspection r Inspection By Date Inspection B Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EAC ❑ Jenuary 1 8 Receive l�ylJanuary 3a---AO-Jffy 1 8 Received By July 31 EktING REMITTANCE $ RE641T BASE _.EXPLANATION AMOUNT DILE CHE ED DATE DATE'. REMITTED AMO NT FEE LESS ..PRORATION., ._ PLUS PENALTY OTHER V OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered 4 t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201