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n ncauons will we rrocessea wnen auumlaeu rropeny t ompieteu. we aure I or gn t he Appucauon. FOR OFFICE IJSE: APPLICATION i (,Non-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 N 1862 and the,{ les and regulations of the San Joaquin Local Hea th District. Exact Site Address /g y//.� E. La OALCI Citylrown ,r��c Iii Owner's Name -1/4NO64Ck 0,1C4X 4A ,r Phone e3g 40 Address City Contractor's Name icense#.T?r//J Business Phone J��O Contractor's Address Emergency Phone - Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes,X No ,I1 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ W WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ I / DISTANCE TO NEAREST: Septic Tank /D� Sewer Lines 100 t Pit Privy — J Sewage Disposal Field //1r) r+ Cesspool/Seepage Pit — Other — 6 Property Line Private Domestic Well/Q 'E Public Domestic Well -- INTENDED USE TYPE OF WELL L2 rf ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 ❑ DOMESTIC/PUBLIC 11t❑ DRIVEN Gauge of Casing d= A&C /�� ✓� ❑ IRRIGATION r,.P GRAVEL PACK Depth of Grout Seal SU ❑ CATHODIC PROTECTIONfrtl❑I�t' ROTARY Type of Grout 13 DISPOSAL OTHER Other Information r ❑ GEOPHYSICAL Surface Seal Installed By PUMP INSTALLATION: Contractor _ S Type of Pump H.P. i PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done - - DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J, ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. UC Home owner or licensed agent's signature certifies the following:"I certitythat in the performance of the work for which this permit is issued, I shall not employ any person in suchmanneras to become subject to workman's compensation laws of California." N Contrac)oes hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this `\) permit is issued, I shall employ p sons subject to workman's compensation laws of California." 1 II for roU ape Nor to grouting and a final Inspection. Signed X - _ Title: 0AZ Date: - L? (Draw Plot Plan on Rever Side) FOR DEPARTMENT USE ONLY PHASE I 4 Application Accepted Bye✓ /l rpm Date Additional Comments: e 1 Grout Inspection se II Final Inspection Inspection By Date Inspection By Dat _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE E REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE �o LESS PRORATION PLUS PENALTY OTHER OTHER - Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.O.Be.21109 STOCKTON,CA SM