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nyynwuwra nm oa rror:easeu ..nw, ouw uurcu riuycuy wu,pm.cu. oe owe ,v oryu i ne nypwauwr. FOR OFFICE USE: APPLICATION ,For 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 for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaqw County r nance No. 1862 and the rull and regulations of the San Joaquin Local Health District. Exact Site Address 12 T /1 cd® es-..� /��[�_ City/Town C Owner's Name Phone -� - ii 2 Address City Contractor's Name /�y License#f_,7 Bu nJess Phone Contractor's Address�,e.Zz_ R�d!!AL 7 �. '�T Emergency Phone �j�� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 'A No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION�ii❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATIONX PUMP REPAIR 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing C ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface S al Installed By: S PUMP INSTALLATION: Contractor � Type of Pump H.P. �.( PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done C 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 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." 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." 1 will call for a G//r., I Inspections prior to grouting and a final Inspection. ` Signed X A -� --L.�L Title: O t�,s4 Date: /� (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASED ` Application Accepted By- Date /z' 3 q Additional Comments: Phase II Grout Inspection (p-ha II Final Inspection Inspection By Date Inspection By ` - to 'I S Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ly 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION — PLUS PENALTY OTHER OTHER 0387 � / Received M Date Receipt No. Permd No.o. �Issue 4:?DaDa1te Marled Delivered — APPLICANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 5520'