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► Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL x ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application iso 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 b9_Q �• 1-1A1JSEt�jCity/Town [ZAL 1 Owner's Name 'i�LOh1 u1(5S f Phone Address Cityto CID V-0-- Contractor's -0 _Contractor's NamelJUl1ti?C�s l3�OS bL1li ,�V COT+vCLicense# �DFSt 3 Business Phone��j��_ a Contractor's Addresss 1� t�QF>1 C �� Emergency Phone IS Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '7< __ No _ TYPE OF WORK (CHECK): NEW WELL® DEEPEN El RECONDITION El DESTRUCTION❑ O WELL CHLORINATION El WELL ABANDONMENT 11 OTHER El PUMP INSTALLATION 11 PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 160 Sewer Lines Pit Privy Sewage Disposal Field /00 t Cesspool/Seepage Pit Other Property Line __ Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A11-0 ?101- IRRIGATION 101-IRRIGATION ® GRAVEL PACK Depth of Grout Seal 50 ❑ CATHODIC PROTECTION ROTARY Type of Grout DerA Lx t? Q ❑ OTHER Other InformatonQ� _�! C7LxTl�l-- ❑ DISPOSAL i � - ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION:INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ Slate Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure A 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:A 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." will call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: _�7 Date: -- (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted ByDate—a-)-�-� a� Additional Comments:— --- — -" t Pthasll Grout Inspection Phas Inspection ,,� Inspection By _ Date Inspection By Date �j Fee Is Due: El ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January I &Received By January 31 ❑ July 1 8 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMI7TCD AMOUNT FEE 433 --- . i LESS PRORATION , PLUS PENALTY ^p OTHER OTHECI 70 Received by Date I Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.130■2009 STOCKTON,CA 9.54��J)