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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION l 4.o2< PUMP & WELL Non -Transferable, Revocable, Sus endable �� ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinan No. 1862 and the rul and r ulations of the San Joaquin Local Health District. Exact Site Address /!l9 = City/Town 5 JrCjQ wL11V eOl Owner's Name �&7 CXa--0A> Z -5;a7 Gfli 7 * c am, % Phone '4�bq- 04jj�-- 0333 r Address ZGL'� �.ST City Contractor's Name R, License # 9l?1 J_ Business Phone Contractor's Address 1401 T ,9D S`lG+Gc�U/L� Emergency Phone 2 0 et -4i3/ 449�= ' 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 INSTALLATIONX , PUMP REPAIR❑ REPLACEMENT ❑ DISTANCE TO NEAREST: Septic Tank _ INTENDED USE Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL ❑ DOMESTIC/PRIVATE �+ ❑ DRILLED DOMESTIC/PUBLIC ❑ DRIVEN ❑ IRRIGATION ❑ GRAVEL PACK ❑ CATHODIC PROTECTION ❑ ROTARY ❑ DISPOSAL ❑ OTHER 4!�VS7/A16 ❑ GEOPHYSICAL Dia. of Well Excavation Dia. of Well Casing Gauge of Casing Depth of Grout Seal Type of Grout Other Information Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump l ^� P. 75 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR:. ❑ State Work Done 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: "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 lawn 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 Grout In ction prior to grouting and a final inspection." l Signed X Title: Date: '6 mow— r - (Draw Plot Plan on.verse i e) Other FOR DEPARTMENT USE ONLY PHASE I (� Application Accepted By Date Additional Comments: Phase II Grout Inspection P se illfivOl Inspection` Inspection By Date Inspection Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 6/Y-3 Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered wee, ,n none. I-- rn. eumnnuueurw. uewi ru 1ae1 F uA7F1'rn61 AVF D n Rn 2nno STACKTON. CA 95201