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FOR OFFICE USE: -- APPLICATION e r Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 wit��/gan Joaquin Count Ordinance No.18612 and the rules and regulations of the San Joaq in Local Health District. Exact Site Address ]�� ..� f' aL City/Town Ltu�<•v Owners Name K Phone Q 3A -,S9/2, Address CityA2etil..rw EoAs g S 2 Q Contractor's Name a License# _ Business Phone7- Contractor's Addres - Emergency Phone 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): " NEW WELL qDEEPEN ❑ RECONDITION DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ r f DISTANCE TO NEAREST: Septic Tank tib -t Sewer Lines .Sly fr Pit Privy �- Sewage Disposal Field/�!) !�_: Cesspool/Seepage Pit Other Property Line //�Private.D,omestic WeU�550 'A Public Domestic Well INTENDED USE ,�dr TYPE OF WELL, ❑ INDUSTRIAL .Fx CABLE TOOL Dia.of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing :F •• ❑ DOMESTIC/PUBLIC ❑ DRIVEN /Gauge of Casing /3 g,4 4�7& r A IRRIGATION ❑`GRD,VEL PACK Depth of Grout Seal �� t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout CE'wr c ❑ DISPOSAL ❑ OTHER -Other Information ❑ GEOPHYSICAL Suiface Seal Installed By: L�)"40 A�. " PUMP INSTALLATION: Contractor , Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: `� Well Diameter Approximate Depth ' Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be ddne in accordance with San 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 thatln the perfor?nance of the work for Which this permit is issued, 1 shall not employ any person in such manner as to become subjgct to"Workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following:"I ceftify that in the performance of the work forwhich this permit is issued, I shall employ per ons subject to workman's compensation IA'ws of CaStphl I w"all for a ut ��ec i n or to grouting and a final inspecIl Signed X -7Lf - Title: Date:< (Draw Plot Plan OR Meyer Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By jJl 031 Date Additional Comments: a e II rout Inspectioncc�� r��r Phase III Final Inspection Inspection 8 Date pr�"ta3L Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑l January 1 &Received By January 31 ❑ July 1&Received By Juty 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT -FEE —4z) LESS PRORATION PLUS PENALTY OTHER OTHER fc. �JV Received by Date Receipt No. Permit No. Isduance Date I Mailed Delivered APPUCANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.boa 2003 STOCKTON,CA 95201