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Applications Will Be Processed When Submitted Properly Comiti. Be Sure To Sign The Ap on. FOR OFFICE USE: APPLICATIONpCT g 1979 (For Non-Transferable, Revocable,Suspendable) �. ENVIRONMENTAL HEALTH P[$MT.1CAQDiN LOCALUMP&WELL HEALTH DISTRICT N (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in c I' tthh,San ,Joaquin County OrdinaJce N.�.1862 and the rules a r lations of the San Joaquin Local Health District. Exact Sitd�re�st.��.t1�li_ Q+��j L��1_� � _ �J/ City/Town Owner's Name qy&e,(� l--a-r' d Phone_�3 Address 98 3-7 A6I d)'eCity Snoc Contractor's Name uoaC- d License# olJS Business Phone %?Yof dkl -7 Contractor's Address f g CPMU!� Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1C No _ TYPE OF WORK (CHECK): NEW WELL$ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ r wl DISTANCE TO NEAREST: Septic Tank 17© Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other + Property Line.3-5— Private Domestic Well Public Domestic Well i INTENDED USE TYPE OF WELL / �y ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing C3 h ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing +r�J ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sealf.- ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor minme, r Type of Pump 44LV r1at Ai:s V&,;wi S lP H.P. PUMP REPLACEMENT: ❑ State Work Done ZCb S''{*it I'il4t" A)U PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth ?fid y 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 for which this l permit is i sued, I shall employ persons subject to workman's compensation laws of California." I will ca ora Gr t In ection prior to grouting and a final inspection. Signed X Title: -- �2 Date: (Draw Plot Plan on Revers Ide) FOR EPARTM T USE ONLY PHASE 1 Application Accepted By Date -19 Additional Comments: hII out Inspection Phase IIWspection Inspection By Date4 Inspection By te Fee IS Due: ❑ ANNUALLY" ❑ PER UNIT %PER SITE ❑ EACH ❑ January 1 & d By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER C>�'-7 o V "79-1150 1o/i1/79 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 95201