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Applications Will Be Processed When Submitted Properly Complet 8e Sure To Sign, FOR 0-FFICE USE: APPLICATION (For Non-Transferable, Revocable;Suspendable) PUMP&WELL f ENVIRONMENTAL HEALTH PERMIT ` R(COMPLETE IN TRIPLICATE) � 5'D X-Z erf." WATER QUALITY cis- d _C Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County.Ordin nce No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town Owner's Name r P ' S.V Phone 3Z 2- Address C-3 "V City Contractor's Name '.'i ' �' Lic6rrse#_33 6. y' ` Business Phone_ ��^aaa i � Contractor's Address :Z f, �� r�— g r r '�en Phone ! / —O -� Is Certificate of Workman's Compensation Ins ranee on ile With SJLH ? lie No C1>1 TYPE OF WORK (CHECK): NEW WEL IK' DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ M5'Isl1-01- :�f�� e'��c: f� WELL CHLORINATION ❑ WELL AI NDONMENT ❑ -OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ o (. REPLACEMENT E] j e C NGS- e in Q�-a yPl:1�a G"<- DISTANCE TO NEAREST: Septic Tank gewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other d Property Line Private Domestic WellPublic Domestic Well f INTENDED USE TYPE OF WELL I 1 I ❑ INDUSTRIAL © CABLE TOOL Dia. of WrAxcavation 9 i"M ❑ DOMESTIC/PRIVATE DRILLED Dia. of"(ell Casing 11 G Y❑ DOMESTIG/PUBLIC ❑ DRIVEN -G�uge of Casing -e i O ❑°IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �� - ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER pts pyi.t Other Information A,w . L . GEOPHYSICAL Surface Seal Installed By: 104 IoF q6%�u-%.a :f1'e 4 1 j PUMP INSTALLATION: tin G Contractor Type of PumpH.P. t' fa PUMP REPLACEMENT: ❑ State Work Done S ( t.& PUMP PUMP REPAIR: Sol- ❑ State Work Done )� G . F �. .� 4 DESTRUCTION OF WELL: Well Diameter Approximate Depth SUS` f Describe Material and Procedure • 1 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 } 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a rout Inspection r'or to grouting and a final inspection. Signed X 11 Title: Date: Ls,-, 7I (Draw Plot Pian on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By 1 ; Date 4 j Additional Comments: Phase 11 Grout Inspection }p Ph se III Final Inspection Inspection By-ALM DateR-_8 17--vi Inspection By pate - e Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT I BASE EXPLANATION - .BILLING REMITTANCE $ - AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE n LESS - PRORATION - PLUS - PENALTY - OTHER OTHER �— s� � Received by ate Receipt No, Permit No. .- Issuance Date -Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA'I ' .