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wppllcalionsWill BeProcessedWhenSubmitted ProperlyCompleted. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP& ELL (COMPLETE IN TRIPLICATE)I(OSSO- WATER QUALITY Application is hereby made to the San Joaquin Local Health Dlstrictforapermit toconstruct andorinstall t ework herein described,This application is made in compliance.wict��h,, San Joaquin County O dinance Na. 1862 and the rules and regulations of the San Joaquin Local Health District, rl:rly ie Exact Site Addressr- i'<lLrTb.2 I1d . City/Town K P7Z>4P_ Owner's Name Phone 333- Address gpgmo City A7! Contractor's Name 72AE(QCd&6 License#751727t Z_ Business Phone Contractor's Address O Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN El RECONDITION DESTRUCTION❑ O WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOI`�o PUMP REPAIR❑ REPLACEMENT❑ 6- DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �--- Sewage Disposal Field 6 Cesspool/Seepage Pit Other Property Line ;9,0') Private Domestic Well —7-1�lublic Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Erxcration-- �'D!DOMESTiC/PRIVATE DRILLED Dia. of Well CaDOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasinIRRIGATION ❑ GRAVEL PACK Depth of Grout l CID- CATHODIC PROTECTION ❑ ROTARY Type of Grout154 4 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 1,45 {C. _JZP-LL ../A16 PUMP INSTALLATION: Contractor._. 61400G10I L{ arl-, P,�GLiiL',___ Type of Pump t5W _ H.P. x PUMP REPLACEMENT: ❑ State Work Done _ PUMP REPAIR: El 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. Home owner or licensed agent's signature certifies the following:1 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 for which this ? permit is issued, I shale employ persons subject to workman's compensation laws of California." I wil call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted ByV,41ate Additional Comments: 0 f Phase II Groul Inspection a III Fi I ection Inspection By ate In ion By Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JWy 31 BILLING REMITTANCE $ REMIT . BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE h LESS V PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 N