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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 9.3 1 W - 51`1 R6 L-1V 7 Po City/Town 40D x f Owner's Name e N Phone Address y NAf SY1 RGL Nr HnCity- LaD r Contractor's Name M, 6Ro ,4wwl License#,�9S!J(')Z? Business Phone *7415-3o-79 Contractor's Address 1♦y Re3[I i Alm Emergency Phone 7yS -3o79 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 5F PUMP REPAIR❑ REPLACEMENT❑ C I i DISTANCE TO NEAREST: Septic Tank 7J Sewer Lines 75 Pit Privy l� Sewage Disposal Field !O O Cesspool/Seepage Pit . Other W Property Line Pr'i ate Domestic_Well /S f Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL_____. CABLE-TOOL Dia.-of Well Excavation DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing -' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /e? Gi.4. ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal. .56 ❑ CATHODIC PROTECTION 9 ROTARY, Type of Grout _54 NO C'.Qh9 --N7 k 1:1 DISPOSAL 11 OTHER Other Information ❑ GEOPHYSICAL I Surface Seal Installed By: PUMP INSTALLATION: Contractor ! !)'1. GULL i Type ofPump H.P. PUMP REPLACEMENT: ❑ State Work Done L PUMP REPAIR: ❑ State Work Done G I 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. I Home owner or licensed agent's signature certifies the following:"I certify thatin the performance of thework for which this permit is issued, 1 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 wil all for a Grout Inspection prior to grouting and a final inspection. Signed X 1 r Title:. Date: (Draw Plot Plan on.Reverse Sidej _ I FOR DEPARTMENT USE ONLY PHASEI ' Application Accepted By Date Additional Comments: Phase 11 Grout Inspection Phase I!A Final Inspection k Inspection By Date Inspection By Date 1 _! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REM IT BASE EXPLANATION DATE DATE'S REMITTED AMOUNT DUE CHECKED AMOUNT PEE $88 , 00. l LESS PRORATION PLUS PENALTY OTHER I OTHER - Received by Date: Receipt No. Permit No. Issuance bate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201