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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL /ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) '? & / 6e n 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 4OT'*/1 OAK C�P,,r-XK . Ac011-y Ce?,Wr City/Town .'57-V-P^ . Owner's Name 0 A 1,T.4 Phone X7 3/--Q 3!V 3 � Address Po- ao x -7 City $77bC_ ,AC 71DAI Contractor's Name AYO.¢G A- A✓tel Fz License Business Phone 6'$1 '7 Contractor's Address Emergency Phone -b! ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >lNo TYPE OF WORK (CHECK): NEW WELL.0 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gaugtiof Casing C- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �l ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 'y 1^ Type of Pump sLe[3 rYI 1t-r AS H.P. & PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done _ DESTRUCTION OF WELL: Well Diameter Approximate 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." ^ I will call for a Grout 1 n prior to grouting and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR D PARTMENT USE ONLY N67-,- 7-W f vtP1 1 /J 4-&r-/ZnZ PHASE I lu�E/�r iGi ue Application Accepted By r Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By7/ r'zs,..l.-..,_ Date 3 �Z 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 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 445 a LESS PRORATION PLUS PENALTY OTHER OTHER 7 � Received by Date Receipt No. Permit No. Issu nce Date , Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201