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Applications Will Be Processed When Submitted Proerly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ,I� (For Non-Transferable, Revocable,Suspendable) V PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Datrictfor apermit toconstruct and/or install the work herein described.This application is made in compliance with San Jo n County Ordinance No..�1$62 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address I 1 ,47 11 - 2 7 City/Town Owner's Name U-3 T>0' '- F3'1% Phone t Address & 0G"D N' "Al-A City /- Contractor's Name Imo - License# 3r710q03usinessPhone ; ` Contractor's Address LSA!) �_% QJ Emergency Phone f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP IIVSTALLATIOf� PUMP REPAIR❑ REPLACEMENT❑ ( DISTANCE TO NEAREST: Septic Tank 1 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line_ Pywat Do stj�ic�'WNV-N_�/_,__F, tblic Domestic Well ri ni TYPE OF WILL yff `( INTENDED�Trn��USE ..,...�,.__.._....,_....._.�.,... .�,,.,._.,.._..�.___._._�____.�,.__ ❑ f - -6AB6E T9L _ Biagi,Wim' B atier�__ ®'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ AVEL PACK Depth of Grout Seal �ti//) - ❑ CATHODIC PROTECTION 4� tZ rY. ROTARY Type of Grout ❑ DISPOSAL OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: �fl� PUMP INSTALLATION: ,,,,,,rppDDrttContractor & ype of Pump 'b ( 6 ZI HIP. PUMP REPLACEMENT: State Work Done PUMP REPAIR: 1❑ State Work Done DESTRUCTION OF WELL: j ell Diameter Appro irrIte Depth jescribe Material and Procedure j I hereby certify that I h0prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, 4n rules and regulations of the San Joaquin Local Health District. - Home owner or licensed ac ent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not em I y any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-. ontracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall n ploy persons subject to workman's compensation laws of California." I I for a Grout In,ep on pr' to outing and a final inspection. Signed X Title: Ju L �" Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By s ` Date-` w�-Additional Comments: V ,� P se II rou nsp - - V P III Final Inspection InspgVion By sec i�h �y Date cJ` GQ i . � t/O -L t Fee Is Due: ❑ ANNUA Y PER NIT ❑ PER SITE ❑ ICH ❑ Ja ua &RqFei d nuar ❑ July 1 &Received By July 31 REMIT %.,e*E EXPLANATION BILLING REMITTA CE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER l i OTHER Received_by_ Date Receipt No. Permit No. I sua ce Date Mailed Delivered APPLICANT—RE t?RitAU—COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201