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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1.� OR OFFICE USE: APPLICATION (For Non-Transierable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) f +,_v4LWATER QUALITY Application is hereby madetothe San Joa-cluin Local Health Districtfora permitto construct and/or install the work herein described.This application is made in compliance�Sa Joaquin County Ordi nce No. 1862 and the�rnul, nd regulations of the San Joaquin Local Health District. t Exact Site Address C, '77 6/A16- ,e_Ae"12 ! TY I'^ �. - N ty/Town C /\I--..C l�lJf Owner's Na `Phone Q?7 1 Address City Contractor's Nam Lie ense (eQ S Business Phone Y D Contractor's Address r gency Phone 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❑ DISTANCE TO NEAREST: Septic Tank t"�� ,-71- Sewer Lines Pit Privy Sewage Disposal Field /19 o 4- cesspool/Seepage Pit Alfan:tt . 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 S�l� DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casings 1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4CZ-0 d"7.-t"-d-z� ❑ CATHODIC PROTECTION ROTARY Type of Grout � -�r .� die► ❑ DISPOSAL ❑ OTHER Other Information S(,! 3•- �Q ❑ GEOPHYSICAL Surface Seal Installed By: 5" Af—[ PUMP INSTALLATION: Contractor 62, bvc ,- Type of Pump SC?-e—, H.P. 'PUMP REPLACEMENT: ❑ State,Work Done J PUMP REPAIR: ❑ State Work Done a DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 1 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 forwhich this 1 permit is issued, I shall employ persons subject to workman's compensation laws of California:" -� - will call for a Grou Ins o rl to grouting and a final inspection. Signed Title: �t�� ( ! Date: ' (Draw Plot Plan on Reverse Side) i F DEP RTMENT USE ONLY i PHASE 9 Application Accepted By 9� �6 Date / Additional Comments: Phase 11 Grout Inspection Phase III FinalAnspection Inspection By Date Inspection By �" l Date . F Fee,Is Due: 13 ANNUALLY ❑ PER UNIT PER SITE 11 EACH 11 January 1 &Received By January 31 ❑ July 1 S Received By July 41 BILLING REMITTANCE $ REM$T BASE EXPLANATION AMOUNT DUE - CHECKED - DATE DATE REMITTED - AMOUNT FEE LESS { PRORATION - j �l PLUS PENALTY OTHER OTHER t 0 J—il f I �-71 =7�1�7 - ar�1 ?q , . Received by Date Receipt No. Permit No Issuance Date Mailed_ Delivered - - - .... _-a-.. - -- - _ . .. _.. .-. APPLICANT—RETURN AL'L COPIES TO: im ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601�E.HAZEL—TON AYE„P.O.Box 2009 STOCKTON,CA 95, -.