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Applications Will Be Processed When Submitted Properly Completed. BMre&'4glgheAppli,WonU FOt76ZFFICE-USE: APPLICATION r� F (For Non-Transferable, Revocable, Suspendable) APR 3 qn IJ80 ENVIRONMVNTEAL HEALTH PERMIT PUMP&WELL SAN J(31tOUIN LOCAL (COMPLETE IN TRIPLICATE) 7��a M1, � , I QUALITY HEALTH DISTRICT Appl ication is hereby made tothe SarYJoaquln Local Health Dlstnctfora permltto construct and/or Install the work herein described.This application is made in complies with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo--agttuuirin Local Health District. Exact Site Addre ss t -C.:. @ �1:i"` y`� City/Town 4C� G►' Owner's Name -13 j r 1 �2_`4-, r'S z,, t-,4 Phone Address / 33 3 .3 Ar\,'Z-i N 5 'f City Contractor's Name iN Zi 3 � <> '= License i Y3'j-�✓ Business Phone Y Contractor's Address I2 c(C Tc�-r-, _ IS!c Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .1 No TYPE OF WORK (CHECK): NEW WELL 0-- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ l DISTANCE TO NEAREST: Septic Tank / b Sewer Lines Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line.?_C Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation a 0-tOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing iIRRIGATION M-GIAVEL PACK Depth of Grout Seal C> _ ❑ CATHODIC PROTECTION M—P- TARY Type of Grout i `J .,r`L _ 6` ❑ DISPOSAL ❑ OTHER Other Information .� ❑ GEOPHYSICAL Surface Seal Installed By: d Q PUMP INSTALLATION: Contractor Type of Pump H.P, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ 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. 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." 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. Signed X(15 ., > Title: Date: .L 1 Z (Draw Plot Plan on Reverse Side) F R DEPA TMENT USE ONLY PHASEI Application Accepted By J Date Additional Comments: Phas9FII Grout spection Phase III Final Inspection Inspection By Date /T Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE 3 q3 LESS PRORATION PLUS PENALTY - OTHER i OTHER IIL� q 2d I Received by - Date Receipt No. Permit No. I suan a Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21309 STOCKTON,CA 95201