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( Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. FOR OFFICIPAPPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL S ENVIRONMENTAL HEALTH PERMIT } (J WATER QUALITY � i (COMPLETE IN TRIPLICATE) i 1 L- 1 i'J` Application is hereby made tothe an Joaquin Local Health(Districtforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis6 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address , Q a57-1A1 7-'D City/Town .. Owner's Name S%�(iE �G ��+EE+ ' Phone 4 . Address a City -7 7 Contractor's Name ��l+C �lIEC� ��Lt/YL� License# �� Business Phone -_57 Contractor's Address 139W3 CZA511��E&Z:i Emergency Phone % �� Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION LJ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 11PUMP INSTALLATION PUMP REPAIR❑ 9EPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines_� Pit Privy Sewage Disposal Field 47"a Cesspool/Seepage Pit Other Property Line_Private Domestic Well /��i Public Domestic Well INTENDED USE TYPE OF WELL _ 13 INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation K DOMESTIC/PRIVATE ❑ DRILLED —Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal 5 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �G ❑ DISPOSAL 13 OTHER Other Information C ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor �Ll Y Type of Pump SECSr H.P. Z 1 PUMP REPLACEMENT- ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter y 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. 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." k 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 bmploy persons subject to workman's compensation laws of California." 1 will all_for a Grout Inspecii n ri r to grouting and a final inspection. Signed X _ Title: Dale: i (Draw Plot Plan on Reverse Side) I OR DEP RTMENT USE ONLY-"'" " PHASE I q Application Accepted By �`� Date d Sf i. Additional Comments: I Phase 11 Grout Inspection ] Phas 1 1 Final pection Inspection By Date Inspection By ate r Fee Is Due: ❑ 'ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT j BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED f DATE DATE REMITTED AMOUNT FEE LESS PRORATION - t PLUS <, PENALTY OTHER OTHER 79 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 STOCKTO ,C 5 1