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j'.. Applications WIII Be Procoused When t3ubrnilled Properly GomplefeU, fie burr To bion The Applicatlon, � Or t i a€_ APPLICATION (For Non-Transferable, Revocable, Suspendable) ,:. PUMP&WELL ENVIRONMENTAL HEALTH PERMIT + D `�AT R QUALITY (COMPLETE IN TRIPLICATE) -�d /[.,� " �' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is k made in compliance with San Joaquin.County Ordinance No. 16621and the rifles and regulations of the San!1 Joaquin Local Health District, yl _.,1 Exact Site Address ~'.- ('ii�()' t'�i:'.�<•c.. ?,, I1't; �(`f �t . 2 14 ' $� City/Town . I..0'_1 Owner's Name r 4 cz, 13' 1 - Phone '^ Address { ttii f`4.g K t� -- City 1 Contractor's Name )') Ir t' i`i NIf _ License # t3usiness Phone__ - - Contractor's Address Emergency Phone Is Certificate of Workman's Compensation I,n�.s,u,,rr�rice on File With SJLHO? Yes `iNo TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL :CHLORINATION ❑ ' WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field )oo Cesspool/Seepage Pit _-- Other - x Property Line 10 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL /� ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ` DOMESTIC/PRIVATE10 ❑ DRILLED Dia. of Welf Casing r /❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ ,f_ fr r,r ' -___ CATHODIC PROTECTION b''ROTARY Type of Grout ___ _• _ _Y7_ �__ _ __�� ❑ 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 !"�' •i '' m;s,'.r f=? r ,,, "�___•_. _-__ _ . E 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. Home owner or licensed agent's signature certifies the following;"I certify that in the performance of the work for which this permit b i is issued, I shall not employ.any person ;n such manner as to become subject to workman's compensation laws of Cai#iornia," + Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued; I shall employ persons subject to workman's compensation taws of California." will call for a Grout Inspection prior�to grouting and a IInal Inspection. 1'Xf�''±rf rf •� Signed K_��. :� ..!� � r.I',i�Ee: _ Date: (Draw Plot..Pi'a�i-on Reverse Side) FOR DEPARTMENT USE ONLY PHASE l / x 'J L� lk Application Accepted By = �� ---- — Date Additional Comments: Phase II.Grout Inspection se III Fin Inspection J Inspection By Date Inspection By -Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S17E ❑ EACH ❑ January) &Recaived By January 31 ❑ July F &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION GAMOUNT DUE CHECKER] ATE GATE REMITTED 1 AMOUNT, FEE LESS PRORATION PLUS PENALTY OTHER OTHER LA o I k euw� Received by N Da l2 RLceipl No:, Permit No. Isuance D,le Mailazi Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMST/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20o9 STOCKTON,CA 95207