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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOROFFICEUSE: APPLICATION (For Non-Transferable, Revocable, Suspendable) / PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY t Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or install the work herein described.This application is made Incompliance with San oaquin Cory Oroiliance No.1562 and the rules and regulations of the San,.loaguin Local Health Di trio. Exact Site Addie ss_sz�/ � i /7'�/% /!J J"AK sYl�,V GT City/Town Owner's Name Phone �$G- SS'7,S✓ : Address v - 5"�" 7 I- A o city-a!26M a.l ON » Contractor's Name/1 E"/ 7]i /2Qr_V License IF3?73 SS Business Phone -33 Y V 2, Contractor's Address Q�OX/78 G(�4J✓)�'V Emergency Phone Is Certificate of Workman's Compensation Insuran eon File With SJLHD7 Yes '� - No TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION❑ ' DESTRUCTION❑ WELL CHLORINATION 13WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION 0 PUMP REPAIR 13 / REPLACEMENT❑ , DISTANCE TO NEAREST: Septic Tank /it Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other C•lJ ./ Property Uni Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL f❑�INDUSTRIAL 11 CABLE TOOL Dia.of Well Excavation /2- .=a DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing F_ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /2 -W IRRIGATION -V'GRAVEL PACK Depth of Grout Seal -S' 1� ❑ CATHODIC PROTECTION XROTARY Type of Grout `T Z(`Qi ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL - - - - - Surface Seal Installed By: PUMP INSTALLATION: Contractor / f Type of Pump - H.P. - A PUMP REPLACEMENT: ❑ State Work Done - •T PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe.Material and Procedure 1 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." 41, Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanceof the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' 1 will call for a rout Inspection prior to grouting and a final Inspection. Signed X ��SS Title: 4.•1111al 1 - S— ze,/ p Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By _ Date Additional Comments: c, - il!hase 11 Grout Inspection /� Ph ,I/LLl Final Inspection Inspection BY �Y—��a Z Date 7-7;r! Fl. Inspecllon BY Al Dale T- t 1 I"Is Due:0 ANNUALLY 0 PER UNIT 0 PER SITE ❑'EACH ❑ Jarl 16 Received By January 31 '❑ July 1 g ReceiPed By July 31 BILLING REMITTANCE. g 'REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNTOUE CHECKED AMOUNT FEE /• �_ /> PLESS RORATION ' I ? 7 - PLUS '- - PENALTY - - OTHFA e - r r ! -5 1XI b Racal by Date - Rapeipt No. Permi Na. - .. arwe DAR, Mailed - Delivered APPLICANT—RETURN ALL COWES TO: ENVSIONMENTAL HEALTH PERMIT/SERVICES telt E.H ELTON AVG,P.O.Bos a STOCKTON,CA ardet