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8fkons Wilrtil'e Processed When Submitted Properly Completed. BeSureToSign TheApplication. fr- 1= APPLICATION FOR OFFI " (For Non-Transferable, Revocable,Suspendable) I �� - PUMP&WELL ENVIRONMENTAL HEALTH PERMIT tj WATER QUALITY (COMPLETE IN TRIPLICATE) I ' Application is hereby made to the SA Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliancet S//a n o --n Joallin. ounty Ordinance No 1862 and the rules and regulations of the San Joaquicxl Health District. i Exact Site Address C�Q'2II Aeo 05 �L� � p T l7 City/Town 5 �� ;�' ,7 Owner's Name C' STS�� I0Y �1 U� �d o Phone Address City ' Contractor's Name d -y-o -, License 4774Z,60-,,;2 Business Phone ✓,,2 - `-' u Contractor's Address C"60, ( s f Emergency Phone !p - S !i , li � Is Certificate of Workman's Compensation'lnsurance on File With SJLHD? Yes 1� No e TYPE OF WORK (CHECK): NEW WELL COY-DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ y WELL CHLORINATION 0F" WELL ABANDONMENT 23'__ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR d REPLACEMENT❑ I� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Ii a Sewage Disposal Field �1GY''� Cesspool/Seepage Pity-- Othe t 1" _ i Property Line 1Q Private Domestic Well -36 r Public Domestic Well �"""-`��`�` � '�` �'_`= INTENDED USE TYPE OF WELL =-4 ❑ II DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Er DOMESTIC/PRIVATE �f ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — ❑ IRRIGATION III ❑ GRAVEL PACK Depth of Grout Seal 5,r � ❑ CATHODIC PROTECTION Ii 21ROTARY Type of Grout J t u ❑ DISPOSAL ❑ OTHER Other Information L( t F 11 GEOPHYSICAL Surface Seal Installed Bv: PUMP INSTALLATION: Contractor �f ,T,,YPe�f Pump H.P.Y/ �- PUMP REPLACEMENT: :I IR State Work"Done t" Or PUMP REPAIR: ❑ State Work Done a *.. _ DESTRUCTION!OF WELL: !' Well Diameter- � '�i - 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..- Homeowner or licensed agent's signature certifies the following:"I 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 I��wil/il��l call for a Grout Inspection prior to�gro Ing and a final inspection. Signed X �T�� l/ ; Title: Date: if 5 .` t (Draw Plot Plan on Reverse Side)y .._ FOR DEPARTMENT USE ONLY PHASE I I *' Application Accepted By Date - Additional Comments: dL ` x L' P as 11 Grout Inspection- F P se III Final Inspection Inspection By DateInspection By A4 bate Fee Is Due:13 ANNUALLY 11 ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January].&Received By January 3 ❑ July 1 &Received By July 31 REMIT t BILLING REMITTANCE _ $ '�..= . BASE II EXPLANATION AMOUNT DUE cHECKEPATE DATE REMITTED AMOUNT D FEET y - - LESS J PRORATION _ PLUS PENALTY OTII-IEA ' OTHER � 77(1�I I -t`Z� \V 6 7 Deceived by .Oaten Receipt No. r Permit No Issuance Date Mailedr-Delivered . \\ APPLICANT—REN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95261 A