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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The*0fication.J*ice � � Uh FOR OFFICE USEAPPLICATION E (For Non-Transferable, Revocable, Suspendable) PUMP&WKh". ENVIRONMENTAL HEALTH PERMIT _ (COMPLETE IN TRIPLICATE) WATER.QUALITY ,� , , , ,, ..�,. GAN .f I.iQ N' �..0�AL Application is hereby made to the San Joaquin Local Hearth District for a permit to construct and/or install the work herein desinb�ed.'SFris!aaspi :§tiifris made in compliance with San Joaq in County.0_rdinance No. 1862 and th 7r es and.regulations of the San Joaquin Local Heal h District. Exact Site Address t tP6 AIA/ c City/Town Owner's Name Phone Address0214 �_ I/fZ_ City SC,4/O� ` Contractor's Name S.6,L..4 � License#e2970/U Business Phone " 3 -Z +f 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 ❑ RECONDITION❑ DESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR` W- REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well F .t INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation W DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing, ❑ IRRIGATION ❑°GRAVEL'PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout E] DISPOSAL ❑ OTHER .. f Other Information ❑ GEOPHYSICAL Surface Seal Installed By:' !� Q PUMP INSTALLATION: Contractor v'c Type of Pump H.P.$ .'� PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done gq,94 x? a hlioie SIL�6 DESTRUCTION OF WELL: Well Diameter Approximate Depth 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. Home owner or licensed agent's signature certifies the following:`'1 certify that in the performance of the work for which this permit S 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws f California." «' I c II fo Grout pe prior to grouting and a final insp4ee ' Signed X Title: Date. - {Draw Plot Plan on Ree) t-! FOR DEPARTMENT USE ONLY l PHASE l C>6- Application Accepted By a&A-CDate Additional Comments: Phase II:Grout Inspection # P s III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER-UNIT ❑ PER"SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE BASE EXPLANATION DATE DATE R ITTED AMOUNT DUE CHECKED AMOUNT FEE L�5 LESS i PRORATION PLUS PENALTY OTHER OTHER V93 Received by Dae Receipt No. Permit No. Issuance.Date Mailed Pelivered i. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r• l