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#601-11cations Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. 61 FOR OFFICE USE: / APPLICATION LA (For Non-Transferable, Revocable,Suspendable) PUMP&WELL T ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) Vp 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 compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address %,'V- /�GD)"`/ City/Town Owner's Name Z11,14 Phone Address / City It 441&111� Contractor's Name 54"O 11? ft a License# if 3-73SO'Business Phone 6 L' — 7L 79r, Contractor's Address ea 0 0 A0 AS#A kldU Emergency Phone Is Certificate of Workman's Compensation Insurance on File Ith SJLHD? Yes k No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑P OTHER ❑ PUMP INSTALLATION IN PUMP REPAIR❑ I 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE D DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICALSurface Seal Installed By: PUMP INSTALLATION: Contractor f'J�� Z=41A1,dO C Type of Pump C!_9;1 -6 is?.a r s- H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP HEIR": State Work Done DESTRUCTION OF WELL: Well Diameter Appr imate Depth 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." IN I will call for a Grout Inspection pr' t r 6ti nd a ' al inspection. QQ Signed X Ll A-ir-A Ile: Q?-& Date: (Draw Plot P n on Reverse Side) FOR DEPARTMENT USE ONLY pp PHASE I Application Accepted By�� n�. Date Additional Comments: cC..•� Phase II Grout Inspection �7�,�Phas III Final Inspection t Inspection By__�To, Date Inspection By�"[ , ="'�--" Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Zeived By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER fty Received by Date Receipt No. Permit No. I suance ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201