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Appl' tios Vill Roc se 1l n Submitted Properly Completed. Be Sure To Sign The Application. ,n t FOR OFFICE USES .,:�� APPLICATION �'`W4For Non-Transferable, Revocable,Suspendable) PUMP&WELL � � � 1 ONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) ;.; 6 �N (��G+ WATER,QUALITY_ Application is hereby made toCS046{ 0�q�,l#�n�o�a Health Distrlctforapermittoconstructand/or install the wo,.k herein described.This application is made in compliance with San Joillh ihn ,ounty Ordinance No..1862 and the.rules and iregulations of the San Joaquin ocal Health District. . - Exact Site Address t v , City/Town "L Owner's Name Phone ' l 5 Address r�/Y► 1 k + . ,j Crty -:,-. Contractor's Name ",�f. �� e `x I License 4 :(:.Business PhonelI b1 _22_CJ Contractor's Address "Emergency Phon t �5i rr►N-� 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 IR PUMP STALLATION ❑ DIY PUMP REPAi j REPLACEMENTIR i2� �srg��e4�d!✓ ei2.+. /Z'� �3dd'®�5f I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Weld INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation lIIi 09 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal JP ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Informationf� ❑ GEOPHYSICAL Surface Seal Installed By: �! i PUMP INSTALLATION: Contractor Type of Pump H:P. r � PUMP REPLACEMENT: ® State Work Donees 7 G; PUMP REPAIR: ❑ State Work Done Q• DESTRUCTION OF WELL: Well-Diameter Approximate Depth ) Describe Material and Procedure4 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit I 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 all for a:Gr;�Jp;Conprior to grouting and a final inspen�_ P5) 1 1114 ,�� '�� Signed X Title: Date: r9c t� � I (Draw Plot Plan on Reverse Side) II,, �N FOR DEPARTMENT USEONLY PHASE 1 _ � b I r�� Application Accepted By Date ff Additional Comments: Phase 11 Grout Inspection _ h e Illiinal Inspection Inspection By Date -- _ Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH, ❑ January 1 &Received By January 131 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE �� F LESS PRORATION PLUS _. PENALTY OTHER ypyA'I k I OTHER — !�? l 3 aV6 - Received by D to Receipt No. Permit No. Issuance Date J� Mailed Delivered. I t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE. FP 0.Boz 2009 STOCKTON,CA 95201