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wppncauons Will De `[uuesssa ""w"wFOR OFFICE USE: APPLICATION �../Non-Transferable,Revocable,Suspendable) �..! PUMP&WELL ENVIRONMENTAL HEALTH PERMIT rCOMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal I the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sante Joaquin Lopal Health District. -*act Site Address_ i y 11-7 �' Jnr 1;: /'Qr/-City/Town L,' U (tY• P Owner's Name Phone Address City LI-irE cz rf Contractor's Name CeeLza. I.- t, Fwd �' License if el 94.4_t- Business Phone ya 74'9 Contractor's Address e7C S" klf tn2a 04 Trtt-4rrrl-l- Emergency Phone l�74 r ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No V" TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONO NELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 1:1 PUMP INSTALLATION ❑ PUMP REPAIR❑ f'^ REPLACEMENT❑ r T DISTANCE TO NEAREST: Septic Tank1I(JU Sewer Lines Pit Privy �. Sewage Disposal Field_I dr1/ Cesspool/Seepage Pit Other= Property Line � Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL C1 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation S40MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing — ❑ DOMESTIC/PUBLIC PTHER ❑ DRIVEN Gauge of Casing❑ IRRIGATION RAVELPACK Depth of Grout Seal❑ CATHODIC PROTECTION OTARY Type of Grout 1 "� 11DISPOSAL Other Information 5'&6 `1 SK ❑ GEOPHYSICAL Surface Seal Installed By: elk W,41- PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done w DESTRUCTION OF WELL: Well Diameter Approximate Depth y.. Describe Material and Procedure C 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. Home owner 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." D Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this T permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed Xy ® Title: �Y/ Date: (Draw Plot Plan on Reverse Side) \ vM''tn\0 FOR DEPARTMENT USE ONLY fit• PHASE I .iQ/Y•AP/Y ``1hF✓rl/ a� -per©� Date S�� Application Accepted ByC - -n Additional Comments: he Pout Inspection Phase III Final Inspection Inspection By r - Date S.ZSF3 Inspection By Vf7 Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 It Received By January 31 ❑ July 1 8 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE y� S B LESS PRORATION PLUS PENALTY OTHER OTHER 3 at Received by Date Receipt No. Permit No. Ise nce Oat Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Bea 2009 STOCKTON,CA 95201 —�