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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOP OFFICE USE: APPLICATION �1- - a or Non-Transferable,'Revoceble,Suspendable)j PUMP&WELL _. ENVIRONM�;E:NTAL HEALTH PERMIT E (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madetothe San Joaquin Local Health District fora permit to construct and/or install thework herein described-This application is 4 made in compliance th San Joaquin County Ordinance No. 1862 and the rules app{{eguiations of the San,�p�aqu�Local Health istrict. Exact Site Address�/h SILO E o o w''I--{,�i,u e Q_„_ City/Tom. (( CA Owner's Na JC AS :31a,, ' PhoneG `- 05'-69 Address 0 h f CityLVgS '7�, Contractor's Name W`STEf?A.) Wim 644LtL�� License# Business'Phone "" 7JcIr 4337- Contractor's 337-Contractor's Address 95147104 147101 fr�?<JTGrD�-�;�`� ✓'� Emergency Phone ':�4O�- 2t r'"' t1L-3 3 Z _ Is Certificate of Workman's Compensation Insurance on File With ISJLHO? Yes No i TYPE OF WORK (CHECK): NEW WELIA* DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ h WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ . REPLACEMENT[] US� DISTANCE TO NEAREST: Septic Tank Se+iver Li.n Pit Privy I,. .vir3 co ud d a 1st Sewage Disposal Field J Cesspool/Seepage Pit Other 6 SwP Property Lined Private Domestic Welles Public Domestic well SFlw+�s •�, INTENDED USE �� TYPE OF WELL r ty AINDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ?5 DRILLED Dia. of Well.Casing k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �C-�7YIhJ'T ❑ DISPOSAL ❑ OTHER = Other Information ❑ GEOPHYSICAL ! Surface Seal Installed By: A]k%J fVet",..5 PUMP INSTALLATION: Contractor 4:7J1> . G7 Type of Pump U1-,-V'C4Q4NC- 7rU V-1a Lc` PUMP REPLACEMENT: ❑ State Work`Done Ca " PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Weil Diameter Approximate Depth •" Describe MTial and4P,roc�e ure -- --- - . I I 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 I, is issued, I shall not employ any person in such manner as to become subjectto Workman's compensation laws of California." Contractor's hiring or sub-contracting signature'certlfies the following:"I certify that in the performance of the work for which this I permit is issued, I shall employ,persons,sobject to workman's compensation laws of California.". is Ill. II for Afout I coon r1 o grouting and a final inspection. t Signed X .J Title: Date: i (Draw Plot Plan on Revers de - ! FOR DEPARTMENT USE ONLY PHASE I � •• { - - i Application AcceptedBy Date '—�� Additional Comments` i 'Phase II Grout Inspection a Ili F' Inspection I Inspection By Date Inspection By 'Date ]1 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE {❑ EACH ❑ January'1 &Received By January 31 ❑ July 1 &Received By July 31 t REMIT :BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHE=CKED DATE DATE" REMITTED AMOUNT i FEE � ao ' 4t LESS PRORATION I j .PLUS ! PENALTY 4 OTHER OTHER. �{ �J Received by Date Receipt-No. r Permit No. Issuance Date Mailed Delivered - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201