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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sur o Sign The Application. FOR OFFICE USE: APPLICATION -e-- (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is I 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 i^�cGf Ld_"�/} Sr- Exact a �G� /Good [;-�� / City/Town -19;7. /- Owner's Name s"-T T !"u6, 16&.% D /' Phone �o-22.8 j Address 1811® L-. �� _ City Al ,17 it Contractor's Name Moonz- 4y 4ep- C-eols. s License#MJF 9,65 Business Phone9/G 37 - 82 9 l Contractor's Addresses v,,A, Emergency Phone S Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE Of:WORK (CHECK): NEW WELL,. DEEPEN ❑ RECONDITION❑ DESTRUCTIONS+ 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 Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ;I ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation .b ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing q ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing r=+ ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal /mac,//.eke A. ❑ CATHODIC PROTECTION J&ROTARY Type of Grout ConC•r`e 7�Ca ❑ DISPOSAL ❑ OTHER Other Information q'n GEOPHYSICAL Surface Seal Installed By: 00-A -'- PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done , PUMP REPAIR: 0 State Work Done « DESTRUCTION OF WELL: Well Diameter -3 Approximate Depth :s-o 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. ! Nome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i 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 I C 11 for Grout Inspect' prior to grouting and a final Inspection. 1 / � Signed X Title;/�s5 SI-�-r�uT4trC5 h Date: -3/3 '8� 1*Q (Draw Plot Plan on Reverse Side) Y/G r i�r /J�le s Ff'✓Acsy�d FOR DEPARTMENT USE ONLY PHASE I Application Accepted By— Date Additional Comments: Phase 11 Grout Inspection 3�7 � ,Phos I Final 1 pecflon 3 Inspectj�,n By e ( Dae � Inspection By li`�f Date 7 � It Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EA H ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED •. ; ni AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER i Received by Dae Receipt No Permit No. Issua ce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON,CA 95201 1