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Ytl Applicalionsl Will Be Processed When Submitted Properlycomplelea. .. ` FOR OFFICE USE: . APPLICATION i (For Non-Transferable, Revocable, Suspendable) ; PUMP&WEtL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (COMPLETE IN TRIPLICATE)" . 91 Application is hereby mace to the San Joaquin Local Healon District for a permit to construct and/or install the work,herein described.This application is, k" made in compliance with San Joaquin county�Ordi, nce No. 1862 and he rules and regulationsof th San Joaquinocal Health District. 01 Exact Site Address'.'. � Phone "- 4Z2_2— Owner's Name City Address License# Business Phone �5:_�� Contractor's Name, 7� Contractor's Address h' CL�P47 ergency Phone f Is Certificate of Workman's Compe"nsation Insurance on ile With SJLHD? Yes X _ No TYPE OF WORK (CHECK): NEW WELA DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR t REPLACEMENT❑ DISTANCE TO NEAREST: septic Tank /fid Sewer Lines Pit Privy Vel Sewage Disposal Field r Cesspool/Seepage Pit Other 1 Property Line Private Domestic Well Public Domestic Well 1 INTENDED USE TYPE OF WELL ❑ INDUSTRIAL j� ❑ CABLE TOOL Dia. of Well Excavation I DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION 1 >4 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION '� i ROTARY Type of Grout — t 11 OTHER Other Information ❑ DISPOSAL �: Q Surface Seal Installed By: ❑ GEOPHYSICAL i It f PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done E PUMP REPAIR: ❑ State Work Done I! Approximate Depth DESTRUCTION OF WELL: Well Diameter 19 Describe Material and Procedure I! �i- ordinances, I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County state law , 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 forwhich 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 Grout"Inspection prior to grouting and a final inspection. ///O—V/ Signed X F Title: Date: I� ( aw Plot Plan on Reverse Side) t I FOR DEPARTMENT USE ONLY PHASE I re- 03 Date -- - Application Accepted By Ip " Additional Comments: J 51' rout Phase III Final Inspection I• P s I G I Inspection By :k. Date Inspection By Date F Fee Is DUB: 13 ANNUALLY ❑ PER UNIT El PER SITE EI EACH ElJanuary 1 &Received By January 31 E] July 1 &Received By Jury 31 REMIT IMIBILLING REMITTANCE $ - .AMOUNT DUE CHECKED - BASE EXPLANATION DATE DATE REM)TTED AMOUNT 4 i FEE ;i O LESS II, i PRORATION 111111 PLUS I PENALTY.i� _ I� OTHER OTHER Received y Date Receipt No.. Permit No. Issuance Date Mailed Delivered I1601 E.HAZEL-TON-AVE.-P.O.Box 2009 STOCKTON,CA 4527 APPLY ANT;RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERYICES i _� I: