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Applications will tie H�ssed When Submitted Properly Completed. Be S�To Sign The Application. r FOR OFFICE USE: �'dviL I_ /�T(FG� APPLICATION IVfJ (For Nan-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 instal I the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 a d the rules and regul ions of the San Joaquin ealth District. Exact Site Address /D 0 �7�v, s J- 0. City/Town Owner's Name GI►r<' 11a 4t e AL/F 1_ _ Phone Address / 0 o L C ,]'• — City J`- Contractor's Name ..-� License# /Business Phone "Y —76 7•E Contractor's Address 20 I-S� E lEt✓ �✓IRrr7 Emergency Phone _. Is Certificate of Workman's Compensation Insurance on File With JLHD9 Yes_.X No \ ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ElRECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 15 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 ❑ DOMESTIC/PUBLIC ❑-DRIVEN Gauge of Casing h IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout d ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ^/ Surface Seal Installed By: PUMP INSTALLATION: Contractor C GZa O,� rw�.0777?1 Type of Pump T r ,A�. Q , H.P. 3 O PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0 State Work Done C09; DESTRUCTION OF WELL: Well Diameter Approximate Dep h 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I w II call for a Grout Inspec p or to gr uling and a final inspection. Signed X Title: Inoma Date: y (Draw Plo Plan on Reverse Side) 7 R DEPARTMENT USE ONLY PHASE I 1�� Dates Application Accepted By- b - /� Additional Comments: Phase If Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January al ❑ July 1 a Received By July 31_ REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE O LESS PRORATION PLUS d J PENALTY OTHER OTHER _.. —79 > .1eoeivad try Date Receipt No Penad NO iunuencii Dale Mailed Delivered c....o.44MFNIY; :'EALTH F2atATTSFRV!CES 1601 E.HAZELTON AVE..P.O.Bila 2109 STOCKTON,CA 95201