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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ��I JR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL I _ ENVIRONMENTAL HEALTH PERMIT r�_ ,. r - ..- . (CQMPLETE IN TRIPLICATE) �'i- WATER QUALITY Application is hereby made to the San Joaquin ocal Health District for a permit to construct and/or install the work herein described.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. Exact site Address fr~ ATrRc Q �7A .�Naa�T�� inti;-$ City/Town -S�4cwro.✓ t Owners Name 04 — Phone ,LOCI- 93s*:- Address City I Contractor's Name C License# Business Phone ZZ3- 7/- 1111 Contractor's Address_ C�'uT�/Jal , U�C�Lt� Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No Q TYPE . WORK (CHECK): NEW WELL❑ DEEPEN ❑ a RECONDITION❑ DESTRUCTION❑ WELL 1`CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ®—PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ a DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 11 II Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 22 ' ❑ INDUSTRIAL © CABLE TOOL Dia, of Well Excavation! ' v� DOMESTIC/PRIVATE MIDRILLED Dia. of Well Casing _ /,J o �J ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing:"'-, ❑ IRR3IGATION ;u ❑ RAVEL PACK Depth of Grout S,i o } ❑iCATHODIC PROTECTION I L1� ROTARY Type of Grout L ❑�.,4��DIS}POSAL ❑ OTHER Other Information iv PUMP IN HY LLAL @ ?! r �ufface,gsal Ins,,,,e Pl7MP INSTALLATION: Contractor 19']' Q`��,� t Type of Pump PUMP REPLACEMENT: ❑ State Work Done_ PUMP REPAIR: ❑ State Work Done r r DESTRUCTION OF WELL: Well Diameter Approximate Depth (,� t ' Describe Material and Procedure ' S i7lp I�cs1C-S L� 1 LJ 1 LL. T C1100 T 4 N DC 5 rR /+� 15 c+ 1 eF1 cf 't ,9 _ + I hereby certify that I have prepared this application and that the work will be one in accordance with San Joaquin ounty,W . ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ' Home owner or licensed agent's signature certifies the following: � 9 f3 g:"I certifyEhatintheperformanceoftheworkafo�whichthis rmit 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 I I call for a Groupectf n p o grouting and a final ins p ction. Signed:1X t 7Title: Date: r 0 � (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I C_ l��b Application Accepted ByDate I Additional Comments:— Phase omments:Phase II Grout Inspection Phase III Final Inspection f Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 S Received By July 31 I BASE EXPLANATION BILLING REMITTANCE REMIT $ i DATE DATE REMITTED AMOUNT DUE CHECKED € AMOUNT F 414 ! LESS PRORATION PLUS � PENALTY OTHER d i OTHER a I Ej .. /3 3,,)-7 4,577 5 t �� Received by 1. Date Receipt No - Permit No. t Issuance Date mailed—Delivered APPLICANT—RETURN ALL COPIESTO: ENYIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009. STOCKTON,CA 95.201 q