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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. `« A FOR OFFICE USE: APPLICATION =r, (For Non-Transferable, Revocable, Suspendable) JP_ _. PUMP&WELL �ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) 2� t-C1t=.u,f�tJl . �- �. —.11111119TER QQUA�ITT_Y 2! - { Application is hereby made to the San Joaquin Local Health - s�trictfor ,permit to cbUrl o d/or install the work herein described.This application is Al I made incompliance with San Joaquin County Ordin� a�ee and re,11 Ions of the San Joaquin Local Health District. Exact Siie Address i q{� . -� ,1 i #mak i��R�3--�'�?-�:��'�'�-1�-��+ „ � City/Town �Lt++,� M�r.77t Owner's Name -S Phone J J 3 q d Address 1&1173 ' 1 City M Q C'V Contractor's Name. A� License#�rC7 �.tac usiness Phone-1-:?V f � 7 Contractor's A.Adgs*� ��l_f Emergency Phone Is Certificate of Workman's Compensations surance on File With SJLHD? Yes' �� No TYPE OF WORK (CHECK): NEW WELL*--"' DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ Q WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION a-�PUMP REPAIR❑ REPLACEMENT❑ - _ t '01- DISTANCE TO NEAREST: Septic Tank Sewer tines /0Z, Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation C BOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing d I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 y � ❑ CATHODIC PROTECTION 2—rMTARY Type of Grout Cl DISPOSAL' - r Ta ❑ OTHER Other Information �- ❑ GEOPHYSICAL Surface Seal Installed By: k PUMP INSTALLATION: Contractor �- < Type of Pumps _ H.P.` PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth A G 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:"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 permit is-issued, I shall employ persons subject to workman's compensation laws of California." I will call for G ut,IInspection prior to growou g end,a final inspection. r Signed �'"f` �a Date cSZ1 16. my Si ned X Title: . ) (Draw Plot Plan on Reverse Side) 01 FOR DEPARTMENT USE ONLY t PHASE I Application Accepted By, `r, Date Additional Comments: Pha I Groutdrnspection _ base I Inspection F C67- Inspection By Date_ ��_/� o _ Inspection ByDate r r q- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` w, BILLING REMITTANCE $ REMIT BASE EXPLANATION - AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT I aL7 00 FEE } LESS PROflATION { PLUS PENALTY OTHER OTHER T l m L/l qa Received by Dale - Receipt No. Permit No fr Issuance Date Mailed- Delivered f ;a APPLICANT—RETURN ALL COPIES TOw: ';*ENVIRONMENTAL HEALTH PERMIT/SERVICES :1601 E.HAZELTON AVE.,P.O.Box 200 52 9-`` STOCKTON,CA 901 ttt � .. -...mo