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` Applications Will Be Processed When SubbmPPLICArTty IONpleted. Be Sure To SignTheApplication. 1 FOR OFFICE USE: --1ror Non-Transferable, Revocable, Suspendable) -. PUMP &WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he described.This application Is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa �p at Health District. Exact Site Address Z �' 2 1'y 6¢v *y Phone own Owner's Name �-`o'^J �v'oo ('CC Phon Address c' fl�r �- Ciry Contractor's Name �L� C'��F-' License 0�f)3 . Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No r TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION❑ DESTRUCTION❑ �L- WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION PUMP REPAIR❑ 6 REPLACEMENT❑ t DISTANCE TO NEAREST: Septic Tank ( o a Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well�._ Public Domestic Well - INTENDED USE TYPE OF WELL ; 11 INDUSTRIAL i 11 CABLE TOOL ell Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of W Casing - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casl ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Se ❑ CATHODIC PROTECTION 13ROTARY Type of Grout \ ❑ DISPOSAL .. 11._.OTHER_ ,Other InforrJlaC-_�. ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Awa � l y� Type of Pump G ov L.e I H.P. �-- PUMP REPLACEMENT: ❑ State Work Done At Q PUMP REPAIR: ❑ State Work Done ' DESTRUCTION OF WEfL4: Well Diameter 81/" ( Appro>iiinnate Depth 00 Describe Material and Procedure I I hereby certify that I have prepared this application and that thew rk will be done in accord@nce with San Joaquin C�unty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i - I Homeowner ol'liciensed agent's signature certifies the following:"I ce+ythat in the performance bf the work for which thisermit is issued, I shall not employ any person in such manner as to become subject to workman's co0pensation laws of Calif§rnia." Contractor's hiring or sub-contracting signature certifies the following:l"I certify that in the perfor ante of the work for whi h this permit is issued, Il shall employ persons subject to workman's composation laws of California. I will a II for a Gr ut Inspection prior to grouting and a 11na1 tnspeeti n. {, Signed Title: CiW'"`J 2v- elate: (Draw Plot Plan on Revers6'Side) FOR DEPARTMENT USE ONLY PHASE I "011 ` -pate Application Accepted y Additional Comments: hese II Grout Inspection ase 1 s�eetlon Inspection By 1 l n Date I Inspection By Final In1Date to f FOB Is DUO: ❑ ANNUAL Y ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 S Received By January 31 A July 1 &Received By July 31 -- ----- — BILLING - -- R- DANCE S REMIT ASE _ EXPLANATION " "- "'-'-"-' " "YdRO DUE-- CHECKED- DATE DATE REMITTED AMOUNT FEE 4-41, O LESS PRORATION PLUS PENALTY OTHER OTHER Received by jDate j, Receipt No. Permit o, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 25201