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Applications Will Be Processed When Submitted Properly Co � dT`V,g r��To'3J The Ap� c�a�!on. FOR OF=FICE USE: t APPLICATION !� (For Non-Transferable, Revocable, da �`+ ENVIRONMENTAL HEALTH PERMIT V PUMP WELL 1/ (COMPLETE IN TRIPLICATE' r- /-)G,:,52. N 2173)l ATER QUALITY SAN JG�AQJ Application is hereby madeto, e San Joaquin Local Health District fora permitto construct ancl/,K, ,"�4worlk herein described.This application is made in compliance wit an Joaquin C unty Ordinance No. 1862 and the. rules and regulations of the San Joaquin Local Health District. Exact Site Address ,� �e�: p d-� `�'�\ Q/V` SCity/Town s Al ��A`T;', Owner's Name Q, P-C, zS 0 L� Phone J Address moi , >�i s_K :Z City N-. Q, — Contractor's Name Cblrt` v* 5 5-i.S F^4, License»/ �iZ 4 �s Business Phone '7 9`�X- Contractor's Aj d�s '�f", 5; res 13/L•,4 Emergency Phone 7 u.i -1 3 4 7 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4— No _ TYPE OF WORK (CHECK): NEW WELL M--'' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I' PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank cam,_ Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line /5 Q Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL %CABLE TOOL Dia. of Well Excavation j 4. DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing /.7_ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .4,4S ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 11�1 3. 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 d s e\ G) ❑ DISPOSAL ❑ OTHER Other Information ...� ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 1 1 , ►'1. �� Type of Pump S L,;j^j H.P. # PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter - Approximate Depth Q Describe Material and Procedure 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 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 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I willcallfor a Grout Inspection prior to grouting and a final inspection.. j q` Signed X�-\7� 5��Y=j-\ Title: ice`-_ 3--�� Date: (Draw Plot Plan on Reverse Side) FO DEPART ENT USE ONLY PHASE Application Accepted By Date Additional Comments: Phase 11 Grout Inspepi ion j�jyt /q Zr Phase I Final I pection �+ Inspection By teU`1' Inspection By '�" '''°' Date 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 REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER cp? 1� f� 7 ' 6L Received by Dat 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 95201