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y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOr1:.tac USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) -�� ENVIRONMENTAL HEALTH PERMIT /� �5� �S PUMP&WEL �, t (COMPLETE IN TRIPLICATE) WATER QUALITY I `� I Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinate Jo No. 1862 and the rules and regulations of the San quin Local Health District. Exact Site Address �17.jam ii/. City/Town C 14 Owner's Name Phone Address 4p ZL J9- City �� I Contractor's Name C'& UAr44 r;' rl#,WMse# 2- Business Phone _74:� E~ Contractor's Address -?-e -Al w x' /F'�.� E ergency Phone o�t/" Is Certificate of Workman's Compensation Insurance on File With SJLHD. Yes No OF WORK (CHECK): NEW WELIX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1400A/4�_ Sewer Lines OIVOS Pit Privy JJd A-/AZ- L sewage Disposal Field Cesspool/Seepage Pit Other &) G R.J AC' Property Line�dB 4r'*O Private Domestic Well /Ve IVB Public Domestic Well INTENDED USE TYPE OF WELL rr ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge Of Casing 1.2 ca . J I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout e ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ,' e PUMP INSTALLATION: ContractorA 40 vz,c >/ I A 4 Type of Pump .5-44A. --H.Pr (A PUMP REPLACEMENT: ❑ State Work Done— PUMP one PUMP REPAIR: ❑ State Work-Done 'i DESTRUCTION OF WELL: Well Diameter Approximate Depth ,r 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 ofLthe 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 pers6ns subject to workman's compensation laws of California." 1^111 call forr�a Grout spec ion prior to grouting and a final inspection. Signed X ,�,/P�6c..g Title: (20 _ Date: (Draw Plat Plan on Reverse Side) - FF!oZDEPRTMENT USE ONLY PHASEI Application Accepted By bate U A ditionallCommpnts: J; r �_z�- ss--- Phase 11 GI I nspe ion/ P e I Final insp ion _ '5) ✓f Inspection By � �� !e / U Inspection By to /�"�/f Fee Is Due: 11 ..ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE REMIT -� -- $ BASE EXPLANATION DATE DATE REMITTED T _ AMOUNT DUE'' CHECKED AMOUNT FEE ef, oo L_ LESS PRORATION PLUS ` PENALTY OTHER / OTHER 357 55 O�,2_SS (c--34-k0 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