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FOR OFFICE USE: APPLICATION 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 fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance N 862 and the les„r and regulations of the San Joaquin ocal Hea th District. Exact Site Address �4 � E7� Le KoC City/Town � cc� �e N Owner's Name VW_N_di.2 [ )FFkIQW41/4,9.�, Phone fe _. Address City Contractor's Name icense q Business Phone �y��Jr,10 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ V�! WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank IOD t Sewer Lines /04 it Pit Privy ---- J Sewage Disposal Field /nn 1`4 Cesspool/!eepage Pit Other 6 Property Line Private Domestic Well/Q_ Public Domestic Well — INTENDED USE TYPE OF WELL ? rf ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing 6 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gaugeof Casing ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal Sf r ❑ CATHODIC PROTECTION ROTARY Type of Grout g–.0 . r� f: ❑ DISPOSAL OTHER Other Information l 11 GEOPHYSICAL Surface Seal Installed By: oke DLit PUMP INSTALLATION: Contractor Type of Pump H.P. l PUMP REPLACEMENT: ❑ State Work Done (" PUMP REPAIR: ❑ State Work Done n� DESTRUCTION OF WELL: Well Diameter Approximate Depth tl t Describe Material and Procedure I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County 1, ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. VC 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this m permit is issued, I shall employ p sons subject to workman's compensation laws of California." I all for a ro s Nor to grouting and a final Inspection. Signed X Title: /Tu Date: (Draw Plot Plan on Rever Side) FOR DEPARTMENT USE ONLY PHASE I �.�A�� Ares / Application Accepted By !J !�P Date Additional Comments: Ph e I Grout Inspection h se II Final Inspection Inspection By--- Date Inspection By Dat Fee Is Due: 11ANNUALLY V❑_PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July/ &Received By July 31 REMIT BILLING REMITTANCE S BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE �.po 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 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9520