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Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 0 0-DICE USE: APPLICATION ' (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMITv QUALITY 3 t— 24 WATER (COMPLETE IN TRIPLICATE) Q ,.�? � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is made in compliance with San Joaquin'County Ordinance No. 1862 an he rules and regulations of the San,Jo quip Loca! Health District. Exact Site Address ��s - c5 �r �J� � City/TownJ��lti/�t� Owner's Name ' 17-0714,Z Phone Address - IZQ 01 �" ity r Contractor's Name; Li ense fi usiness Phone i Contractor's Address Emergency Emergency Phone Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No TYPE OF WORK (HECK): NEW kl_L- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line i Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL. ❑ IN�TRIAL ❑ CABLE TOOL Dia. of Well Excavation- 0 L4-1 OMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing �f ❑ DOMESTIC/PUBLIC ❑ DRIVEN\ Gauge of Casing 1 4 ❑ IRRIGATION I 13GRAVEL PACK ' Depth of Grout Seal � i El CATHODIC PROTECTION 15'ROTARY' ROTARY` E Type of Grout ❑ DISPOSAL ❑ OTHER ! _Other Information ❑ GEOPHYSICAL. Surface Seal Installed By: PUMP INSTALLATION: I Contractor O.d�v'L, /�_,,,,al)-�l "P .'h •- Type of Pump s � Z! H P z PUMP REPLACEMENT:. ❑ State Work Done I �] PUMP REPAIR: ❑ State Work Done Cy ; DESTRUCTION OF WELL: Well Diameter Approximate Depth t ., Describe Material and Procedure �n f `tz, 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 s 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." t Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich th"is permit is issued. I shall employ persons subject to workman's compensation laws of California." t I wil call for a Grout I pectin rlor to grouting and a final inspection. i .i 4 Signed X Title: _".. _ ..__ Date: I. (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments.-_ base II Grout Inspection f ti ase Itl Final Inspection l Inspection By Date 0�2+ f Inspection B Date IO e I / Fee Is Due: ❑ ANNUALLY -'❑`PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juhy 1 &Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED DATE - DATE REMITTED AMOUNT FEE LESS ....; r�vJ J PRORATION - 1. [U f'�d t L�✓71'<- 0 vm• ] f•�/ PLUS p _ 4 P PENALTY t I I OTHER ""il �0`R,�-i0 YG�" r, b fa'�'-c .. <• GC 4 J1-N OTHER d-z Lc) 1/0 eor" .f e,r i,060-6y Date d Receipt No.' Permit No. Issuance Date , Mailed Delivered' APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 ,.