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ApplicationsWill BeProcessedWhen Submitted ProperlyCompleted. BeSureTo Sign The Application. �R_RFFICE USE: APPLICATION (For Non-Transierable, Revocable, Suspendable) PUMP&WELL ' ENVIRONMENTAL HEALTH PERMIT COMPLETE IN TRIPLICATE WAT UALITYj� Application is hereby made tothe San Joaquin Local Health Districttora permit to construct and/or install the work herein described.This application is made in coin liance��nnrrlt Sar a i t r an h .,ccyu�bps� a e ulations of the San Joaquin Local Health District. p {71 tts sY .2. �C��K. g f Exact Site AddressCity/Town ��i�C _ Owner's Name 45WIlp- Phone Address /ll l_/ l City Contractor's Name ,Gf/1S5' !!A� License# '.��1��_ Business•Phone Contractor's Address �. / lYT�/f��iC�Y-S%` i� p- Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4e,"' No . TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ � REPLACEMENT❑ A DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field /?'0'0" Cesspool/Seepage Pit Other F Property Linen,s -hPrivateDomestic Well zS/ Public Domestic Well INTENDED USE TYPE OF WELL m 3 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVA'-IF ❑ DRILLED _Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of,Casing;1N.f1'y ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECT ION + ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER ' ' J, Other Information.-_--} ❑ GEOPHYSICAL ,'` j Surface-Seal-Installed-By: -- PUMP INSTALLATION: Contractor W,55 •z*/1/ z4jl- G_bwl% 1_1/14{ B/ Type of Pump 7-G��21 /I/� f H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter1 l { ,1Approximate Depth.�y Describe Maferial an�'ProcedUre I I hereby certify that I have prepared this application and th t.the work ill be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San�Joaqui nL --o��cal Health Dist ICt.� `: '3' '• Home owner or licensed agent's signature certifies the following:"I certifyTthat in the perlformance of the work forwhich this permit is issued, I shall not employ any person in such manner as o 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 w.ork_forwhich this, permit is issued, I shall employ persons subject to workmen's compensation Daws ofj:California." will call for a Grout inspection prior to grouting and a final insp �.Y.- ! )7 9p Signed X kSTERN -WELL,DRILLING C :, LTD. Title: ��' #�— �S�.c d.� 4 Date: �� (Draw Plot Plan on Reverse Side) fI -'t FOR DEPARTMENT USE ONLY PHASEI A Application'Accepted Byf 3 ``1 w -*^ �n, � Date ' Additional Commehts. i Phase II Grout Inspection phas# 111 Final Inspection Inspection By Date r Inspection By c + oz Fee Is Due: 13 ANNUALLY " ❑ PER UNIT El PER SITE .❑ EACH 11Januar V1 &Received By January 31 ❑ Ju &Received By July 31 r B#CLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE S `"�.', �:.; t. .�.-.,. --•� I LESS PRORATION PLUS PENALTY - OTHER ., Received by Date I ,_ Receipt No. Permit No. Issuande Aa a Mailed Delivered .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bax 2009' STOCKTON,CA 95201 "—' nz