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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. W-OPPlet-USE: APPLICATION f! c, 5-5--i ,� (For Non-Transferable, Revocable, Suspendable) �o �;y/ PUMP&WELL I ENVIRONMENTAL HEALTH PERMIT cla>,> (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San 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. 1862 and the rules and regulations of the Sa Joaquin Local Health District. Exact Site Address,'C 3 )!�/r'� r� 6 1`�'I,V/7 AIM 74 /t�l� City/Town 704',IV�Cd� Owner's Name A-116/� // A I?�1/.I��7 Phone Address S`? 4 3 1. ,G /�//�l » f� City— Contractor's ity Contractor's Name C4.9Pt'!� WAIL 4 kleIfiO icense#� Business Phone Contractor's Address�•L7.c�� G'_r �G' � ��f/� � Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ 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 /;2- DOMESTIC/PRIVATE ZDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 12 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ^ ❑ "GEOPHYSICAL Surface Seal Installed By: l PUMP INSTALLATION: Contractor J Type of Pump H.P. W PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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 permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a`Gr. t In ection prior to grouting and a final inspection. a Signed X Title: {/,i'l.P� Date: � i 7 0_1(Draw Plot Plan on Reverse Side) FOR DEPARTM T USE ONLY PHASEI o Application Accepted By Date 9' Or,— 7/ Additional Comments: Phase II Grout Inspection Phase III Final�Insppction Inspection By Date Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER S 26 5% I� 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.Bax 2009 STOCKTON,CA 95201