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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. 12 �_ 1-7 v-1 3 FOR OFFICE USE: APPLICATION (For Non-Transferablc,Revocable,Suspendable) PUMP&WELL 'i ENVIRONMENTAL HEALTH PERMIT V WATER QUALITY (COMPLETE IN TRIPLICATE) Application is hereby madeto the San Joaquin Local Health Dis 18fi2 a dora phe rulos anst egulatioo s oftthe San Joaquin)Local Healltth Dist.This ricplication is made in compliance wi San Joaquin CoSlnty Ord��nce,Ntq• / 7gy/Town _,5 Exact Site Add7 ress >> n �S'jR2 Phone 6_x_ 9,5Z� L Owner's Name City s��C'��ee -- Address License# ?.Z T� Business Phone Contractor's Name �� T� a Emergency Phone Contractor's Address i _Z- -- No --F Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ — TYPE OF WORK (CHECK): NEW WELL ❑❑ OTHER 11 ITIO U❑P INSTALLATION 0 PUMP REPAIR❑ WELL CHLORINATION C3 WELL WELL ABANDONMENTr REPLACEMENT❑ I (56 - Pit Privy ` Sewer Lines Other DISTANCE TO NEAREST: Septic Tanky '( �- 10 Cesspool/Seepage Pit Sewage Disposal Field l A t public Domestic Well Property Line_/ f Private Domestic Well �rz�— TYPE OF WELL INTENDED USE Dia. of Well Excavation ❑ INDUSTRIAL ❑ CABLE TOOL 1, C3 DRILLED Dia. of Well Casing ; /v DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing �� r ❑ DOMESTIC/PUBLIC 'st GRAVEL PACK Depth of Grout Seal 11 IRRIGATION Type of Grout ❑ CATHODIC PROTECTION , ROTARY ❑ OTHER Other Information ❑ DISPOSAL Surface Seal Installed By: ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done Approximate Depth DESTRUCTION OF WELL: Well Diameter 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. n Homeowner ora licensed employ any signature n in such mannerasfollowing: becomefy that in the performance of the work subject to workman's compensation for of California."it I`- Cissued, I shall no p Y 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 ersons subject to workman's compensation laws of California." 1 ' call for Gro Ins c' n prior to grouting and a final inspection. Date: Title: Signed X (Draw Plot Plan on Reverse' ide) FOR DEPARTMENT USE ONLY PHASE 1 Date Application Accepted By Additional Comments: Phase II Final Inspection Phase 11 ro t Insp top ,., �� Inspection By Date Inspection ByAk, D e� �, .2+i-2 1 &Received By July 31 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei ed By January 31 ❑ July REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE F- LESS PRORATION PLUS PENALTY OTHER OTHER 100 <�-� $ I Date Receipt No Permit No Iss ante D e Mailed Delivered Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 . 1 1reuT_AFTURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES