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i� lications Will Be PTa6e31ed When 5ubmlt4ed Properly rl Completed leted B3 Sura To Sign The Application APPLICATION (For Non-Transferabl- Revocable Suspondable) -- PUMP&WELL ENVIRONMENTAL HEALTH PERMIT t (COMPLETE IN TRIPLICATE) WATER QUALITY Application is herebymade to the San Joaqur7 Local Healtf•Oistnct fora permit to constructana/onnstall the work herein described This application is 3# made rn compliance with San Joaquin County Ordinance No 1852 and the rules and ragulatlons or the San Joaquin Local Health Oistriet � 05 3 vaterlOC fir' _ CiI /T1w, StOCtCt- n Exact SI•p Address ___ ___ —_-- Y , :'hank i edl-nc3 Phone � Owner s Name —— — Address City---- Contractors it Contractors Name1'Jorman' s at0l S•�Ste�tts I cense b__'6'69Fi Business Fhone Q3Z-3210___ )Z Con•actors Address 4243 Cerrylani A_v_P. — Emergency Phone �Sc�rriP Is Certificate of Workman s Compensation insurance on File With SJLHD'i Yes X No TYPE OF WORK (CHECK) NEW WELL❑ i]E- 'EN© RECONDITION❑ OESTRUCT IONO WELL CHLORINAT ON ❑ WELD ABANDONMENT❑ OTHrP ❑ PUMP INSTAL TION Cf' PUMP REPAIR 13 ; R£PLACEMENTO s' " DISTANCE TO NEAREST Septic Tank —_ _—�— Sewer ernes —_ _ Pit Privy Sewage Disposal Flc.d— Cesspool/Seepage Pit____Other----.c— Properly ther cProperly Line Private Domestic Well Public DomestrC Well INTENDED USE TYPE OF WELL _ ❑ INDUSTRIAL ❑ CABLE TOOL Dia of Well Excavation ❑ DONIEST.C'PRIVATE ❑ DRILLED Dia of Well Casing — !~ ❑ DOMESTIC,PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHEP O ter Information '_ -` ❑ GEOPHYSICAL Surface Seat Installed By n PUwtPIN5 LLATIO F Contractor t'oornarllC 'pater systems � /111 C — Type of Pump submeL si 3e H P 3 4 T xoulled exiatin txmn and. itistaile3 Heir- PUMP REPLACEMENT State Work Done___ _n-- { •^� PUMP REPAIR 1:1State Work Dane DESTRUCTION OF WELL. Well Diameter Approximate Depth i�F Describe Material and Proced.ire r4 ri1;� 3.^ 1 x _ I hereby certify that I have prepared this application and that the work rill be done .n accordance with San Joaquin Com ay- ordinances state taws and rules and regulations of the San Joaquin Local Health District r� Home owne-or licensed agents s•gnature certifies the following I certify that in the performanceof lhP work for which this permit is Issued I shall not employ any person In such manner as to becorre sublet,to workman s compensation laws of Callfo-nia. , Contractors hiring or sub-contracting signature certifies the f»ilowing I certify that in the performance of the work forwhtch this permit is issued I shall employ pe,sons subject to workman s compensation icws a'Callfornid" ti f r 1 will Call for a Grout Inspection prior to grouting and a'Inal Inspection t s c�� Title w 3 SI red X 7i S�"t^r�.✓ �� — �' s/ —- Date•J o__ 3 4 5 g (Draw Plot Plan on Retarse Side) 4' FOR DEPARTME14T LISE ONLY 1 { r ` t PHASE I —1� s 1/J Application Accepted 8y_—�-lllta �, —. date G r R � r+ddAional Comrren[s _—_ -ra"'—� —N �- Ph ine II Grout Inspectl6n Phase 11' BI Inspection — r inspection fay— Date 'nspection B/ _ sate Fee Is Due ❑ ANNUALLY ❑ Pt9R UNIT i! PER BITE ❑ EACH ❑ Ja•uary 1 d Received By January 71 ❑Juiy 18 Received lay July 3t REMIT BILLING REMiYTANCE S i BASE �E%PLANATION DATE DATE REMITTED AMOUNT AMOUNT ' •F - FEE 3 a3 I CESS ,.., P,10i rtON — I. f _ OT,�EFI E _ f Dares Rece�ot M Permit Nn hsuance Dass Mmdea plfrrErrlr f1 t1 APPLICANT—' RN ALL COPIES TO' ENV1ROMMENTAL HU LTN IMMSEPVICES IW1 I-14AZELTON AVE„PO Bev IOW STOCIrTON CA 211=1 12