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Applications Will Be Process d When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ( or Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRO ,MENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) — Y�A R QUALITY Application is hereby madetotheSanJ aqui n Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San J aqui ounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address e ( City/Town —1I c& RC c-ez— i 0"1 44 i • "I-ft 4t 3 3 3 R Owner's Name SAal 3OAc�t}t� Ct3 v � Z `1 Phone 1 CJd Address 22 L- 1=. . L,)EC3 CZ-- City %Tpe--1(-.-t Contractor's Name k E to to it,1 G5 I,12.0 3 License# 2R L A 13 Business Phone S4 S— 1 1 L S ) Contractor's Address %SZS PC—LA tJ bD LG FAOIVE S7 . Emergency 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 13 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1 000 1 Sewer Lines t Q 0 0 � Pit Privy Sewage Disposal Field 0 Q c) Cesspool/Seepage Pit 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 12- DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3/110 -7 C ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 201 ❑ CATHODIC PROTECTION ROTARY Type of Grout C-e"C ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: J4 E A31.1 IQ G S 'g(Za S PUMP INSTALLATION: Contractor Qc')it- 11,1 LL- So U 1 P 141 G—*►% U . Type of Pump S L g!-9 C L.0 H.P. S PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth �1 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. 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 will call for aGrout Inspect'on prior to grouting and a final inspection. < Signed ? ''� Title: C Date: Z Z (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date Additional Comments: as. 11 Grout Inspection P s III Final Inspection 2t p a Inspection By Date -ZJ Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE (� LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issbanob Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201