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Applications Will Be Processed WWen Sobmitted ProperlyCompleted. Be sureTosign IneAppucaxi t APPLICATION FOR.OFF:$� USE: _ y (For Non-Transterable, Revocable,Suspendable) SUMP&WELL _D ENVIRONMENTAL HEALTH PERMIT Ql -X/4 Igo (COMPLETE IN TRIPLICATE) r WATER QUALITY Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.ThisappTicationis made in compliance with San Joaquin County —dinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addre/s�s /Q r / /e r— City/Town ".9 Cec Y77 d d Owner's Name Cy' cl 0 `s Phol(' 2 -3 9 Address &0O `_ / � / City ��' 7— / 7 cr Contractor's Name��r✓I ol1 i L ill ll D",Ih-Ai q License# �� Business Phone � Contractor's Address 2 1Obt3 Rdcg a=+ a Emergency Phone Alf— Is Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No X. TYPE OF WORK (CHECK): NEW WELD. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR 13 REPLACEMENT❑ //'s�, DISTANCE TO NEAREST: Septic Tank Q "f"Y" Sewer Lines�,'�Q-�� Pit Privy O/L/Ps Sewage Di Field � /� tZ. Cesspool/Seepage Pit /Vd /i!C Other 6�✓� Property Line/_c2'r Private Domestic Well Public Domestic Well At INTENDED USE TYPE OF WELL 42 ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation Ile, 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal L4—0 - 4 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ill «✓ ❑ DISPOSAL ❑ OTHER Other Information Weil O ❑ GEOPHYSICAL / Surface Seal Installed By: PUMP INSTALLATION: Contractor d e. +"+ �f+ 'U1 +H Prde c Type of Pump /l7 c+��/'- H.P. 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. 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." I will all for a Grout Ins ction prior to grouting and a final inspection. Signed X .� "� � J Ti -r Date: �►2— S 7' (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By(&4 U. Date Z J Additional Comments: Phas II Grout Ins echo P se III Fi I Inspection Inspection By Y pate Inspection By Date !o 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 5 1?q 1111, Z_*:>3LA o S' _ s� -7 Received by Date Receipt o. Permit No. las once ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOl CA 95201