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Applications Will Be Processed When Submitted Properly Complgteo WSt T The AppficatNon. FOR OFFICE USE: APRLfC ► ,�. (For Non-Transferabl9;ffie o Sespendable) PUMP&WELL ENVIRONMENTAV AL EIRW1 � Z , U (COMPLETE IN TRIPLICATE) WATERALITY �� Application is hereby made to the San Joaquin Local District for a permit to construQSt�r�dX�}hSt��rk herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the ruleCA� r�i�ir root an Jo uin Local Health District. Exact Site Address -� ®a �� h/u �. �� 111...... City/Town p .Kr. Owner's Name /i Phone Address 2OCl City /�m e�- Contractor's Name .P 0 License# Zf � � Business Phone 4 ,� _�t?J S Contractor's Address &'° Emergency Phone r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ) TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDI N 11DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIRC#;_t REPLACEMENT❑ 4-= DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL FDODUSTRIAL 13CABLE TOOL Dia.of Well Excavation MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: -Contractor Type of Pump H.P. PUMP REPLACEMENT: 2�tate Work Done PUMP REPAIR: tate Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth �- Describe Material and Procedure 1 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. Homeowner 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 a Grout Inspection prior to grouting and a final inspection. � n Signed X Y' A&;27 14 Title: )II Date: (Draw Plot Plan on Reverse Sidi) FOR DEPARTMENT USE ONLY PHASEI _ Application Accepted By ` ` '' "� --�`"'�� Date Additional Comments: Phase II Grout Inspection Phhase,ll Final Inspection Inspection By—AAia 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 REMITTED AMOUNT DUE CHECKED AMOUNT FEES y LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Isshance a Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201