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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION 01? � a (For Non-Transferable, Gevocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL ' (COMPLETE IN TRIPLICATE) WATER QUALITY OQ Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework.herein described.This application is ==C made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 019 ®01 N• 7 V 71 W 4-y At 4 City/Town A C ck rv%-p O Owner's Name e K u It— Phone Via- 7 f el Address .7 no IV '' � �w'�v Ad City C- res o Contractor's Name i,C License# /�3 Business Phone .9'4. $`— �� 7 ■ Contractor's Address .?©V0 N• S,6 LE CFmergency Phone o N S r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT"❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 0 REPLACEMENT❑`,' f, nn,,'� -- DISTANCE TO NEAREST: Septic T " -Tank-/0 / ,fes Sewer'Lines/-.5-r.4. Iv Pit PriivT 0 OJ� Sewage Disposal Field ti&1,0— Cess/Afov-I/S,eepage Pit Al V-00 e-- Other Property Line 040 Private Domestic Well r C Public Domestic Well ISO 'L�° INTENDED USE TYPE OF WELL � �yl ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation /�_ DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1A I R- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 'Q t' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout -ern L. #L! ❑ DISPOSAL ❑ OTHER Other Information nn ❑ GEOPHYSICAL Surface Seal Installed PUMP INSTALLATION: Contractor L4- 40 V,')Cr K pe t^l/i C Type of Pump r H,P. 1 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure i I hereby certify that I have prepared this application an_d 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 for which this permit is issued,"I shall employ persons subject to workman's compensation laws of California." !,oVII call for a Gro Inspection prior to g outing and a final inspection. Signed X �� Titfe: 4!7 " Date:- r' (Draw Plot Plan on Reverse Side) FOR DEPART ENT"USE ONLY I PHASE Application Accepted By Date / Additional Comments: PhaseI Grout Inspection a Pha III Final Inspection Inspection By Date i� �J d•---� Inspection By Date Fee Is Due: 13 ANNUALLY ❑ PER UNIT iLX PER SITE ❑ EACH ❑ January 1 &Received By January 31' ❑ July 1 a Received By July 31 r REMIT BILLING REMITTANCE $ $. BASE EXPLANATION AMOUNT DUE CHECKED 3- DATE DATE REMITTED AMOUNT FEE S Q66A� "} LESS PRORATION w PLUS PENALTY OTHER OTHER s 7 -�LLz1� ' `7:9-11`�tj 1�/13/7J _ 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