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VY nun:ceseu nuenauunueu Ye T ucDunt nu�.yn .,,c..yY,,••o FOR OFFICE USE: APPLICATION ...' (For Non-Transferable,Revocable,Suspendabl— G PUMP&WELL ENVIRONMENTAL HEALTH PERMIT } (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance wit[h/San Joaquin Count�y/O�rdinance No. 18612 and the rules and regulations of the San Joagyin Local Health District. Exact Site Address ]�� ( F-L+''w• '� �� City/Town L t.udc.v Owner's Name K Phone - - Address - City ICAfZ dz l R'Sax 6 Contractor's Name A License#y ,�� Business Phone �^ k lU OQ Contractors Addre Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No R , �' t TYPE OF WORK (CHECK): - NEW WELL4 DEEPEN 13 RECONDITION DESTRUCTION❑ 4 Y L E C� � Y WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ / 1 DISTANCE TO NEAREST: Septic Tank !;23 H Sewer Lines Pit Privy Sewage Disposal Field -k Cesspool/Seepage Pit Other Property Line J/9'�Private, mestic WeU c50'k- Public Domestic Well �- INTENDED USE ..! TYPE OF WELL, ❑ INDUSTRIAL ./3l CABLE TOOL Dia.•of Well Excavation Pk,DOMESTIC/PRIVATE ❑ DRILLED Did. of Well Casing 13DOMESTIC/PUBLIC ❑ DRIVEN /Gauge of Casing �(�.S_ �41 A IRRIGATION ❑-GRAVEL PACK Depth of Grout Seal O r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,P A4 ❑ DISPOSAL 0 OTHER -other Information -- - ❑ GEOPHYSICAL Su-rface Seal Installed By: � PUMP INSTALLATION: Contractor "1, `.t Type of Pump •{ 'kr H.P. PUMP REPLACEMENT: ❑ State Work Done << ` PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 11 Approximate Depth ' Describe Material and Procedure I hereby certify that I have prepared this application and that the work will bed ne in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Heal thi District. Home owner or licensed agent's signature ceeR1ies the following:"I certify that iln thf performance of the work for pnhich this permit is issued, I shall not employ any person in such manner as to become subj ot;tolworkman's`epmpensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:'t c at in theperformance of the work for which this permit is issued, 1 shall employ per ons subject to workman's comp'"e'�I/t join I s of Califp?nia." I will all for a ut e n or to grouting and a final inspecgon. -7 / Signed X - Title: /Wa H T - _ Date:�f Vk_r mak' (Draw Plot Plan on Ffe f Side) - - FOR DEPARTMENT U,SE ONLY r PHASE I Date Application Accepted By Additional Comments: a e 11 rout Inspection Phase III Final Inspection Inspection B Date r(X� Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0,January 1 a Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE l U P LESS PRORATION - — PLUS PENALTY --- OTHER OTHER Received by Date Receipt No. Permit No. - - j-uande Date I- Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1401 E.HAIELTON AVE.,P.O.Boa alis STOCKTON.CA 9=1 -