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Applications Will Be Processed When SubmittedProperlyCompleted_. BeSureToSignTheApplicalion.— FI5R oFrICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) J� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT f (COMPLETE IN TRIPLICATE) t` ^�- C 1� AaRA'ATER QljALITY L 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 made-in compliance with Sar;Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. Exact Site Address 7.00 rzASo ,%,Df- Of RF41) AJ""E City/Town Owner's Name ILL. Irl rVo�. Ti Phone 446's "703 Address ia3tt►. W. HPrGF3o%.%A r� ! City tTb Contractor's Name eA L,. o License# ,? i 566 Business Phone Contractor's Address "%%I S- Q RAkol" Emergency Phone— AYA- Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � 4/ No V TYPE OF WORK (CHECK): NEW WELL '"DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank I Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line. 1A Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation l0 94 M DOMESTIC/PRIVATE ❑ DRILLED {: ; Dia.�of'WeII Casing ❑'DOMESTIC/PUB LIC LJ DRIVEN Gauge of CasingL ❑.IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout I�ii►S f�IL�1.f� (� ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor '. ..- . Type-of-Pump. -- c!�;. _ H.P. PUMP REPLACEMENT:; O=-State-Work-Done --- -- PUMP REPAIR: ; - ❑ State Work Done t DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have preaared this application-and Ithat the work will be done in accordance with San Joaquj County ordinances tate laws, and rules and regulations of the San Joaquin Local Health District. } . Homeowner or licensed agent's-signature-certifies-the following:"I certify thatinthe performance of the work for which this permit 1 is issued, I shall not employ any person-in such manner as to become su�ject to workman's compensation laws of California.•' +� C raclors-hiring ors—ub-contracting signature certifies the following:"I cerxify-that in the performance of the work fo"rwhich this_ - p it is issued,.l shall empl person subject to•'workman's compensatbri laws of California." I all for a t In It prior 'grouting and a final ins ction.T,/��J a Signed XTitle: �F�1C+Gb� � Q Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT,USE ONLY PHASE I . Application Acceptedf6 4 l Date Additional Comments: y -- ', hase 11 Grou Inspection Phase III Final Inspection* Inspection By X --- --Date--- ��L ----..Inspection-By— Date- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By July 31 _ REMIT BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED Q] AMOUNT FEES LESS PRORATION — PLUS PENALTY OTHER OTHER Received by Date Receipt Np. P rmit No. —ls4uanc6 Date Mailed Delivered { APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/CERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ,.STOCKTON,CA 952r . �"- }