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Appli l yotisiW Be Processed Wh bmitted Properly Completed.Be Sure To Sign The Application. SE: :;; APPLICATION t r t? jFor Non-Transferable, Revocable,Suspendable) PUMP&WELL q ELPMACINMENTAL HEALTH PERMIT (COMPLETE IN RIPL ATE) JJEA TH DIS I F+CT 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 w' h San�Joa iin Clpunty divan a No. 2 d the rules and regulations of the San J.Qagpin Lqsaljiealth District. Exact Site Address � A4VZ City/Town cS�� Owner's Name Phone Address City Contractor's Name !3!» %'n o"t S Q 7rw icense#,4*'2 o9( Business Phone !FZ/-3.340 Contractor's Address-642 0 1.xJX")4 f. $'j'Ks✓ Emergency Phone -3/' _5.;2_.e0 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ REPLACEMENT❑ __.__W. DISTANCE TO NEAREST: Septic Tank 4DO r-/ Sewer Lines,2200 Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Otter Property Line Private Domestic Well Public Domestic Well dy ` INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing 6 9DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` � IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -.50 J. ❑ CATHODIC PROTECTION ROTARY Type of Grout C Je em e,..>T ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: pI�r�_(�2V�. r`t�,.L'— PUMP INSTALLATION: ContractorYN\Wr S Grr� Type of Pump scab M_Q r5;bL-#-- H.P. S 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 ofinances,_state laws, and rules and regulations of the San Joaquin Local Health District. Horne owner 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 I r pection prior to grouting and a final inspec/Side) Signed X Title: Date: 7 Z(Draw Plot Plan on Reve FOR DEPARTMENT USE ONLY PHASE [ Application Accepted By 05 Date 5-A ib'" Additional Comment Phase I Grout Inspection � �aselll Final In ctior Inspection By – /-2L Date Inspe on Bv,� £-- ate kx,4 X`^"Z 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 DATEDATE REMITTED AMOUNT DUE CHECKED / AMOUNT FEE g$/ LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Is uance D to Mailed Delivered .— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201