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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.y FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) _x PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE INT IPLICATE) At..".8z' WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance wit-1 an Joaq in C unt rdinance No. 18fi2 and the rule and regulations of he San Joaquin Local Health District. 0 t Exact Site Address (,[� L� Cikwn /f2*c yPO Owner's Name R I!nJ `�Zz .t MOS4 nw.e enr r� Phone + 3 r — 6 2Fe - `i Address City Q-gcc Contractor's Name License#,_a,_?j Business Phone �11 - .2k10 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN Q0 RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ f i DISTANCE TO NEAREST: Septic Tank Sewer Lines�2<d '!.— Pit Privy Sewage Disposal f=ield t Cesspool/Seepage Pit Other Property Line + Private Domestic Well -�O ��— Public Domestic Well INTENDED USE TYPE OF WELL w / ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation c6,4 • 1r,91& J.yu AJ_ J/ ❑ DOMESTIC/PRIVATE ElE DRILLED Dia. of Well Casing Z6 � o��c,nr.ut� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing__64. � d?A qr ,��u]!& IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal j ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information "_ y, ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT- ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure j t 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 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 I permit is issued, I shall employ ons subject to workman's compensation laws of California." f i will call for a Gr t I s ec' rior to grouting and a final inspection. I f Signed X Title: Ag4nv Date: h (Dr w Plot Plan on Rever Side) I I FOR DEPARTMENT USE ONLY PHASE I ) If Application Accepted By to ' '- Additional Comments: I Phase 11 Grout Inspection JEACI P e NI I !n e o!" ^� P � �� C� mCInspection By Date Inspection By DateFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ January 1 &Received By January 3 ❑ July 1 &Received By Ju 31 BILLING REMITTANCE $ REMIT i BASE EXPLANATION AMOUNT DUE CHECKE DATE DATE REMITTED !t AMDU Z FEE LESS PRORATION €, PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered f' - APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, 1 _.