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Applications Will Be Processed When Submitted Properly Completed. Be lilc�sign The Application. .: I N Fd�FFICE USE: APPLICATION AUG 17 1979 (For Non-Transferable, Revocable, Suspendable) ' PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN JCA,QUIN LOCAL (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH. DISTRICT k 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 with San Joaquin County Ordina ce No. 186 and rules and r ulations of the San Joaquin Local Health District. Exact Site Address E P City/Town a Owner's Name *.+1-_(;LLe 6?'0 rJCt.Sia)F�-X-r JE Ar f. _ Phone Address 7i S ___ zT.El_N+,A)G U CityE SC.4L.n A.) 2 Contractor's Name 43T13AJ 181-.4 td---T U-- rt-P License#R 9o3S5� Business Phone M Contractor's Address PO 12 Pis 6/,r�S 01 hi.0 DES'T'p Emergency Phone i 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 ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ F DISTANCE TO NEAREST: Septic Tank '" Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well G INTENDED USE TYPE OF WELL �!a ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal dft ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor TftAf I S ,t . R tJ IK- 10 Type of Pump 'Do_ S no A) H.P. 4 a PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth j Describe Material and Procedure f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County E ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ an_y person in such manner as to become subject to workman's compensation I1V of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance o�yhe forwhich this # permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X 1t/L Z_e-Z.C� Title: QTS c_ Date: F �7� j, (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I �, Application Accepted By Date Additional Comments: Phase It Grout Inspection P I Final I ection Inspection By Date Inspection By e Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED /Jl AMOUNT FEE # LESS CJ PRORATION PLUS PENALTY OTHER 1 OTHER ck.-- Received by Date Receipt No. Permit No.. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201