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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OF icE USE: APPLICATION ,: . (For Non-Transferable, Revocable;Suspendable) PUMP&WELL ,N ENVIRONMENTAL HEALTH PiRMIT Q WATER, UALITY, (COMPLETE IN TRIPLICATE) .- �' 1'.t t,t ',, 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 C unty Ordina No.;1862 and the rules and re ulations of the San Joaquin total Health.District.- Exact Site Address a 2xS ® © City/Town Owner's'Name M%1' /f�� F fi9b l ' r Phone . Address f.2 R Cam x 'City, F Contractor's NameLicense`#�; , 1 r,.� h Business Phone `5? f �, nye •� i . ' .f� a' ` Contractor's Address D -jry Emergency'Phone Is Certificate of Workman's Com ensation Insurance on File With SJLHD? Yes_ No 0 TYPE OF WORK (CHECK): NEW WELLX�I DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP IN, ❑ $ PUMP REPAIR REPLACEMENT❑ f�"Q ""'E- I DISTANCE TO NEAREST: Septic Tank �[? Sewer Lines Pit Privy Sewage Disposal Field 04 1 4 Cesspool/Seepage Pit Other Property Line42 �4d Private DomesticTWell Public Domestic Well INTENDED USE TYPE OF,WELL 1 �� !+ 11 INDUSTRIAL 13 CABLE TOOL Dia. of Welt Excavation �DOMESTIC/PUBLIC DOMESTIC/PRIVATE ❑ DRILLEDDia. of'Well"Casing❑ DRIVEN Gauge of Casing CI P y ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information V' El GEOPHYSICAL Surface Seal installed By: r2, &✓Z. V1 PUMP INSTALLATION: Contractor F Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: t ❑ 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." t r Contractor's hiring or sub-contracting signature certifies the following:`"I certify that in the performance of the work for which this permit is issue I shall employ rsons subject to workman's compensation laws of California." call for r Ins p ti prior to grouting and a'final inspection. ; Signed X Title: T/4 G//i �.t Date: (Draw Plot Plan on Revers ide). F FOR DEPARTMENT USE ONLY i PHASE0*7 en _ - Date �. Application Accepte y Additional Comme is PFja a Grout Inspection „ se 11 Final Inspection ' Inspection By (- Date 7-- ) Inspection By Date r , By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ` ❑ PER SITEj�❑- EACH ❑ January 1 &Received By January 31 ❑ July &ReceiKed REMITuly31 BASE "EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED• AMOUNT _ q o FEE LESS t PRORATION PLUS PENALTY OTHER S OTHER r Received by Date Receipt No. - - F Permit No. Issua a Date - Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201