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-ris-.•--.- •...6 i.,..��.. wv..,,..vvr, yv.q v.uu,pm.vu.ueawe ru al n ,nen ncauun. II FOR OFFICE USE: ?J 1 APPLICATION J�_ %,.{For Non-Transferable, Revocable,Suspendabi PUMP&WELL gp /OAQUIN IRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICA'1 LTH DISTRICT WATER QUALITY Application is hereby madeto a an Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address^s1eA.,}�fLL�f >� el.`S City/Town �� Owner's Name MaKTeea 14e! sZ • A/ed ASS 1Lr:a T" Phone v,z 3 Address City 7Ya Contractor's Name E License rivZ g6 Z!, Business Phone +� 3� y Contractor's Address f80 b`h" ii t-0 in r Emergency Phone r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v No 4-1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ — WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI� REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICALJJ Surface Seal Installed By: PUMP INSTALLATION: Contractor 4YA F/i'!' I� Type of Pump S�sd�ai��e H.P. /�L PUMP REPLACEMENT: ❑ State Work Done ✓ a&il+L PUMP REPAIR: 11 State Work Done—�' �,_� —fl DESTRUCTION OF WELL: Well Diameter Approximate Depth O Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rill ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final Inspection. � Signed X Title: ,I i Date: 7-2 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE �p1�� II� Application Accepted By�\ 5`A^"- ""� ^-� � Date VA_� �C• Additional Comments: Phase 11 Grout Inspection Ph flIII Final Inspectionpp� 'A� Inspection By �hn Date Inspection 1^' Date _�- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE s LESS PRORATION PLUS PENALTY OTHER OTHER ) / If" J IO �' Received by 'Datb Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.O.Be.20010 STOCKTON.CA 95201