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ApplicationsWill BeProcessedWhen Submitted ProperlyCompleted. Be Sure To Sign The Application. FOOFFICEUSE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL }�I (COMPLETE IN TRIPLICATE) WATER QUALITY /If- 23 0 -�f Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instalithework herein described.This application is 6 made in compliance with San Joaquin County Ordinance No. 1562 and the rules and regulations of the San Joaquin Local Health District. N Exact Site Address 19 Y W' f�I��A/G/te l O,� ZOO' C- Z �src� City/Town :S;TeC1e Z:0/V Owner's Name C&1./r. YI/ArZ`17 SL�'i VlCh CC, Phone _ye4 — �g7� Address , S T/= --- City -9374yC A/ Contractor's Name GIAM W011.4 L74111P C-er 41WLicense# Business Phone AY160- 6-11-1 y Contractor's Address. 02'/ E. 611191P 6/? 141/•)Y Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_1( No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONIV WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other _n 1 Property Line Private Domestic Well Public Domestic Well I' INTENDED USE TYPE OF WELL w ❑ INDUSTRIAL ® CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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:1 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I w' all f a out Ins p �ec�tion prior to grouting and a final inspecti �y Signed X 4 elL- LC Title: � Date: �� i�?� f (Draw Plot Plan on Reverse Side) q FOR DEPARTMENT USE ONLY PHASE I Application Accepted ByZeiDate 2 C OV / r Additional Comments: Phas 11 rout Inspection Phase III Final Inspection t Inspection By Datrev I '� Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I�PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS U ur PRORATION PLUS PENALTY OTHER s OTHER t=> Received by Date Receipt No. ermit No. issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boz 2009 STOCKTON,11 11 01