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App f al ns Will Be Processed Whe mitred Properly Completed. Be Sure To Sign The Applica�lon. (W1 PFFICEUSE: 2 APPLICATION //-.iS y,� �J? yd Ili �i q IO Non-Transferable, Revocable, Suspendable) �— . 12L$'0 F_- ISAr44 (� — 1-70—&( PUMP&WELL r SAN JlDt UIN EI IRLONMENTAL HEALTH PERMIT 2n7a, I✓� HEALTH DISTRICT WATER QUALITY C.0hti IeTi�.1 da7r �U n e_ 3J,1ypl (COMPLETE IN TRIPLICATE) P r Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is r 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��'t?r7 laN�t ��fl/1�_,j� s+,/� —.Z�� -S� � City/Town �+%7/0C k Toy Owner's Name _Ian rCtl .Scz _ Phone Address .- �1 [7_cl.� L c _��k_e_r._ City St2 A_712 cfl I rvlarlce rI eA. rI tng Corp. Contractor's Name License Z77 9z3 Business Phone cc " Contractor's Address — Emergency Phone --� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >l No 06 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION, PUMP REPAIR❑ REPLACEMENT❑ " DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field — - Cesspool/Seepage Pit. Other - Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL _ ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation + ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 13 4 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ! .e 'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal /❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: f PUMP INSTALLATION: i/ Contractor Purviance Drillers Dolling Corp. Type of Pump _rtA H.P. D -` PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done l`� a DESTRUCTION OF WELL: _._—Wel! Diameter- Approximate Depth '-� Describe Material and Procedure . 1 r 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f� 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 Js 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 employ persons subject to workman's compensation laws of California.--_' - ° I.will call fora ro` Jn ection prior to grouting and a final inspection. C Signed.X _ rR Title: 7 j' S ��v+ Date: `g/ (DrdWPlot Plan on Reverse Side) a; _t FOR DEPARTMENT USE ONLY PHASE l ' Application Accepted By �� Date- -1;L3 Additional Comments- -Phase-II Grout Inspection` -"` as I! I I Inspection ` Inspection By. Cf _ Date Inspection By Date G —�� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Received By July 31 REMIT BILLING REMITTANCE $ I BASE EXPLANATION DATE DATE REMtTTEp AMOUNT DUE CHECKED AMOUNT FEE -4... 1 LESS i PRORATION PLUS PENALTY OTHER I OTHER J k lea 3�7 UfaYf Q 9I�6/ki Received by Date Receipt No. Permit No. issuance Date Mai d Delivered ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201