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,plications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ter: APPLICATION (For Non-Transferable, Revocable,Suspendable) ' ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework 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 4/72 $O 19,-e—bPl2 04Le cat.-2a City/Town L1,A149C/U Owner's Named �Ohi'IIIC�c�iJ Phone _d Address 679 City .STo C/GTonJ J Contractor's Name /YJiiie7710 /�c�mp q� ,�t"o�pp License# X36 0-YS/ Business Phone 8�7 -6 3 7 y� Contractor's-Address S ��e 0 �o,9+0—O K�� Emergency Phone 03 9 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION ElDESTRUCTION❑ V WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank Uf Sewer Lines Pit Privy AJCI'> .A,. Sewage Disposal Field /A1x� Cesspool/Seepage Pit Sz)/ Other A207---_ Property LineAO6Private Domestic Well ,uJ7y2—Public Domestic Well NyiV 12— INTENDED USE TYPE OF WELL , ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _ _ ® DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing J ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / Z ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal v� U ❑ CATHODIC PROTECTION W ROTARY Type of Grout �� - -y- co-e7 C ❑ DISPOSAL ❑ OTHER Other Information S A o� ❑ GEOPHYSICAL Surface Seal Installed By: ryc. L PUMP INSTALLATION: Contractor7_?y,r� P, o /(/ Tiy G Type of Pump�S`�_d,� 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 em Io ersons subject to workman's compensation laws of California." ill call for Lit p tion grouting and a final inspection. Si Title: Ce 42 m AAJ," &-r, Date: d/8o (Draw Plot Plan on Reverse Side) FORD PARTME T USE ONLY PHASEI r Application Accepted By Date ( �� Additional Comments: Phase II Grout Inspection ftase III Final Insp tion Q" , Inspection By Date Inspection B to ! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT NrPER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LLLJJJ �,/ LESS PRORATION _ PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. I Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201