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Applications Will BAP"Cessed When Submitted Properly Completed.Be SOo Sign The Application. / F R OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) 07 �. ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) �a'y� Vile"'4 WATER QUALITY Q Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County_O`rdinance No. 18r62 Qnd the rules and regulations of the Sen Joaquin cal Ith District. Exact Site Address g'ad fA) C ✓e�e rD CityPTown .�, Owner's NameIstidr ` ,fib fl aft, �ar� Phone Address �'� WI. CA (pe— City Contractor's Name -�'�+`+� d1;IN `� al, �� Licenses L4?—7ulfBusiness Phone '- �«1 -'76 r7 Contractors Address '�'e"�A 6% _ d Emergency Phone Is Certificate of Workman's Compensation Insurance on File With LHD? -Yea X No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION I] DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR IS .i 1 REPLACEMENT❑ _ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL I* INDUSTRIAL ❑ CABLE TOOL Dia. Of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -� ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I ❑ CATHODIC PROTECTION`, ❑ ROTARY Type of Grout ❑ DISPOSAL + ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed v PUMP INSTALLATION: Contractor .� Type of Pump — H.P. GO PUMP REPLACEMENT: ❑ State Work Done I PUMP REPAIR: Stale Work Done &-e* AAIP 91 1 DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure k I hereby certify that I have prepared this application and that the work will b'e done in accordance with'Son 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:"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 call fo�1 � Ins Ing and a final inspection. ! Signed Title: vm-/ _ Date: __ 1 (Draw Plo Ian on Reverse Side) IF FOR EPARTMENT USE ONLY PHASEI yr. Y Application Accepted By - Date a Additional Comments: r Phase 11 Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date i 1 Fee IS Due:11 ANNUALLY PER UNIT Or PER SITE 11 EACH E3 January 1 6 Received By January 31 ❑July 1 8 Received 9y July 31 I - REMIT �- BASE EXPLANATION - BILLING - REMITTANCE 3 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE y� LESS ? PRORATION i PLUS PENALTY , I OTHER y �( OTHER .r jReeelvad by - Date Recelp[No. Permit No - louanea Date1... Mailed Delivered APPLICANT—RETURN ALL COPIES TO,. ENVIRONMENTAL HEALTH PERMI I—MRVIOEB .1801 E.HA TON AVE,P.O.age 21102 STOCKTON,CA 952H