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Appecauons will De Processeu wnen suommea t•ropeny completeo.ne sure I o sign i ne Appucauon. )>t FOR OFFICE USE: APPLICATION .waor Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the Sen Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquiunty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. n Co Exact Site Address �PZ 2 L% 6eP -rY City/Town &A_L_t— / Owner's Name 9 O PJ Z11106 tl�S Phone 3(1,187 " 3 r_ 7 Y Address R 1 City Contractor's Name �Z�L� N twsE License If 086 D3 Business Phone w Contractor's Address ev;,-t Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ) TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ �. WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 (9- REPLACEMENT❑ y l U DISTANCE TO NEAREST: i Septic Tank l o C. Sewer Lines Pit Privy I Sewage Disposal Field Cesspool/Seepage Pit - Other Property Line Private Domestic WeJI_X__ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL DialbfWell Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of W Casing ❑ DOMESTIC/PUBLIC 1 ❑ DRIVEN Gauge of Cast 13IRRIGATION - ' 11 GRAVEL PACK Depth of Grout Se ❑ CATHODIC PROTECTIO}N.- ❑ ROTARY Type of Grout 1.--- -- ❑ DISPOSAL -, i - 0 OTHER \ Other Informatio,T on�_ n� 11 GEOPHYSICAL Surface Seal Installed:By: i PUMP INSTALLATION: Contractor _ 1 L1z Ii fT i Type of Pump oeJ Le H.P. PUMP REPLACEMENT: ❑ State Work Done R Q PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WEkly I Well Diameter ff/11 Approinuate Depth o 0 iDescribe Material and Procedure I hereby certify that 1 have prepared this application and that the wc rk will be done in accordance with San Joaquinunty ( '1 ordinances,state laws, and rules and regulations of the San Joaquin ocal Health District. I - Home owner oeliclensed agent's signature certifies the following:"I Carl fy that in the performance bf the work for which this 1 ermit is issued, 1 shall riot employ any person in such manner as to become subject to workman's cc pensation laws of Calif rnia." Contractor's hiring or subcontracting signature certifies the following:"I certify that in the perforr, lance of the work forwhh It thist permit is issued, 11shall employ persons subject to workman's compe sation laws of California.!¢ 1 will `aj��11—lor_a Gr t Inspection prior to grouting and a final inspection p O Signed X W_` Title: "w'v v- te: ` — �^ a 2 (Draw Plot Plan on Reverse'Side) nFOR DEPARTMENT USE ONLY Application ion Accepted 3y �"""�'� � ` --Date Additional Comments: Kase 11 Grout Inspection ase I Final Inst tion Inspection By Date Inspection By ' IDate tom Fee is Due: ❑ ANNUAL Y ❑ PER UNIT ❑ PER SITE ❑ EACH I I January 1 &Received By January 31 July 1 a Received By July 31 -- -- -' — BILLING - TTANOE .f DATE DATE REMITTED REMIT ASE EAPLANATION -� UE— AMOUNT FEELESS T a PRORATION I �— PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit o. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE..P.O.Boa 20119 STOCKTON,CA 55001