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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. JF; R,.PF ICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) " T PUMP&WELL ENVIRONMENTAL HEALTH PERMIT I (COMPLETE IN TRIPLICATE) WATER QUALITY i Application is hereby madeto theSan Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is i made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address S. '= City/Town Owner's Name 3C,&& C'httle C A(J j4. . _ Phone_ 0_4- 716 i_ Address- City lYl �f� Contractor's NameCy4Lrl '_7'FG /, J�l�L( ld License# Business Phone Contractor's Address Emergency Phone _ f Is Certificate of Workman's Compensation Insu nce on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank k4^,f0 F7• Sewer Lines Pit Privy a Disposal Sewa Dis Field /f)Ir g p �— Cesspool/Seepage Pit Other 1 Property Line Private Domestic Well Public Domestic Well I r INTENDED USE TYPE OF WELL 1 C ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE . ` ❑ DRILLED Dia. of Well Casing f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 200C 460 *IRRIGATION JWGRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Io,ROTARY Type of Grout Z94422&Z77E ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: � _. PUMP INSTALLATION: Contractor Type of Pump H.P. 4— PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performan.ceof 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 will call r Grout,Inspection prior to grouting and a final inspection. Signed X ! Title: Date: /' (Draw Plot Plan on Reverse Side) s �LRDEP RTMENT SE ONLY PHASEA Application Accepted By--.. ® � Date ?x l d Additional Comments: Phase II Grout Inspection Phase III f=inal Inspection Inspection By Date Ins ec n By Date � - Fee IS Due: ElANNUALLY El PER UNIT ❑ PER SITE ❑ EAC Janu 1 &Received By January 31 ff my 1 R ceiv® By July 3 ^�-" BASE EXPLANATION BILLING ANC - AM To V DATE DATE A f FEE LESS PRORATION 1 PLUS PENALTY OTHER 0 I OTHER © ' Received by _= Date - Receipt No Permit No _ - Issuarice Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201