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ppncauonswill BeProcessedWhenSubmitted Properly Com IIII "r6-Yoi)grVTh4ApT. ion. FOR OFFICE USE: APPLICATION �II AA�� / _ J (For Non-Transferable, Revocable, Suspendal AN 2 1 1981 _ ENVIRON_ MEN, AL HEALTH P RMIT PUMP&WELL (COMPLETE IN TRIPLICATE) --Z4oaD_./J, ,4Ey4�LWATER QUALITY l�Ei�� SIS I Oe�7�-2Eo -�� Application is hereby made to the an`Jo„aquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is made in compliance with San Joaquin C unty rdinance No. iff a d the rules a d reg I ions Of the San Joaquin Local Health District. Exact Site Address City/Town _W1100 in Owner's Name `4 f' U �P e ti --: `4 Address City Contractor's Name d _ ('+ ,CS no. 5C N 3 License# r4 C 3-E, 1111111 ss Phone Contractor's Ad1 `� c �" / Emergency Phone 7q5 26 u "~ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 'lN l TYPE OF WORK (CHECK): NEW WELL®DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ET-.w PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /45_4:�, Sewer Lines C3 Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 2 4Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 1 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �•n ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 95—MTARY Type of Grout � c ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: t PUMP INSTALLATION: Contractor C Z e. Cz�. 5 -i- ` iiI, Type of Pump f>dg H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: j ❑ State Work Done i DESTRUCTION OF WE Wed Diameter Approximate Depth ~� �y[Jp L Describe Material and Procedure ±, r _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state taws, 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 shaft 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. Signed X Title: ` t Date: _ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Pha a 11 Grout nspection6/ hale I I spection inspection By Date— _ Inspection By A -4 ZY ��1 I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan ary 31 ❑ July 1 Received By July 31 BASE EXPLANATION BILLINGREMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS T QQ ((fit PRORATION PLUS PENALTY OTHER Jt 1 OTHER Received by Date Receipt No, Permit No- Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201