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r'Mrnt.o11 Vlla tt 111 vc rtVreaaiM ttIeC11 VVVII IILICM r IVNCIIf 4V111'/ICLCV.OC Vy1C IV 01I'IFJ�l111r iS 11U11, -� FOR OFFICE-USE: APPLICATION 1�11 IIIc For Non-Transferable,Revocable, Suspend able; i I _ ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtforapermittoconstruct and/or install the work.hereindescribed. Ica ' is made.in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations.of the San Joa Exact Site Address / [.a s q e h t City/Town - Owner's Name �TEI/� mit! Phone AddressA-Ag- y� Contractor's Name City_ , 'D CL/ License#3_3�� Business Phone 7 3 377 1 Contractor's Address :pe aox 444 _ Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo— TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITiON'U DESTRUCTIO -� WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 11 PUMP INSTALLATION REPLACEMENT❑ / PUMP REPAIR1 ❑ DISTANCE TO NEAREST: Septic Tank OSewerLines- Pit Privy ' Sewage Disposal Field �—+`' rpSspool/Se.,.age .,..r.....;�.,�o�wyc Pit' �---- Other Property Line L�O Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia, of Well Excavation-149�r .QST: ,Sp DOMESTIC/PRIVATE — DRILLED Dia, of Well Casing` ❑ DOMESTIC/PUBLIC ❑ DRIVEN — ❑ Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seale' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout_9 11 DISPOSAL" ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP IfYSTALLAT Ort: Contractor >�45 Type of Pump H.P. �Z PUMP REPLACEMENT: 11 state Work bone: �`- PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL Well Diameter Approximate Depth' > Describe Material and Procedure 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 ` is issued, 1 shall not em to P Y any person in such manner as to become S'66 ect 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 for which this 1 permit is issued,'l shall employ persons subject to workman's compensation Paws of Californis:" t•wA' all for a Gr ut Inspectio rfor tb grouting and a final inspection. ..,[� 1Z I Signed Date: ,; (Qraw�lot.f?lan_on Reverse Side) i i s FOR DEPARTMENT USE ONLY � -PHASE I 4. Application Accepted lay Additional Comments,° Date Phase 11 Grout Inspection Pse I11 Final Inspection ) �J Inspection By Date Inspection By pa Fee Is Due: ❑ ANNUALliY .z ❑ PER UNIT ❑ PER SITE [].EACH ❑ January 1&Received By January 31 ❑ July 1&Received By Jvly 31 i BASS EXPLANATION BILLING REMITTANCE - $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE Q� AMOUNT LE55 PRORATION PLUS PENALTY OTHER' OTHER I Received by ate �` / — � Receipt Na Permit No. Issua ce Date Mailed Delivere APPLICANT—RETURN ALL COPIES,TO;,. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HA2ELTON AVE.-,P.O.Bax 2009 STOCKTON;CA 95201.