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Applicatlorls Will Be Processed When Submitted Properly C&4pleled. Be Sure To Sign The Application. r 14 T _ APPLICATION _Fe�R+4FF.�CE USE: _ / (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT w ' (COMPLETE IN TRIPLICATE) �c� `p ,�. •4c i,4B ER QUALITY - Application is hereby madeto the an Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1 62 and the rules and regulatio s-rofftthe San o al Health District. Exact Site Address 65 rA ityv R t- { 1 P e � CLt Lcy)'T S Owner's Name I _a-, Address r7 r? k it Contractor'sName License# - us' ess Phone Contractor's Address Emergency Phone• • Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLS" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑Y 00 WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION.4 PUMP REPAIR❑ REPLACEMENT ] I 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 ❑� �INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation UP6OMESTIC/PRIVATE LO e --1— ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing CZ I U 11 IRRIGATION 1:1 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ""— V, -` ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL. ``�� -- Surface Seal In By: PUMP I CATION:"' � Contractor Wex__ H P `. Type of Pump —, PUMP REPLACEMENT: ❑ State Work Done ❑ State Work Done PUMP REPAIR: -- � DESTRUCTION OF WELL: Well Diameter Approximate Depth J Describe Material and Procedureµ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County y ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. S Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t 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 for which this permit is issued, k shall employ persons subject to workman's compensation laws of California." c I for a Grout Inspectio prior to gr ting and incl inspection. Signed'�X Title: ` c ` i 4Date.-. (bra P o Ian on Reverse Side) FOR DEPARTMENT USE ONLY PHASEKX Application Accepted By 71 Datelo-1 r Additional Comments: i *; ase 11 r nspection 7 /� h III Final Inspection Q� Inspection By f jl�afe. � r Inspection By t Date Fee IS Due:❑ ANNUALL-Y _. -❑ PER UN4T..v, , ❑ , ER S1TE ❑ EACH ❑ January 1 &Received By January 31 July 1 8 Received By July 31 k _ REMIT ' w BILLING REMITTANCE e $ AMOUNT DUE CHECKED s BASE EXPLANATION *� DATE DATE REMITTED '' AMOUNT w. FEE fz r, LESS PRORATi6W-^_- .- PLUS _ •� r r < 'i ti :,l-r. ^E't. yY,,'°� +' ,ta+-..e�.sv �4. r t PENALTY -' - OTHER OTHER'S 134ti p Received by Date Receipt No. - Permit No. Issuance Dale Mailed Delivered j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201