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Applications Will Be Processed When Submitted Properly Completed. Be Sur ff4ign The Application. Jill FOROFFICE USE: APPLICATION MAR 28 1981 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL MPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT pplication Is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin CountyOrdinance No.1862 and the rules and regulations of the Be �oaquLocal Health District Exact Site Address g V� City/Town bbGG Owner's Name PAT f- A L•,r a none . B•�� _7290 � Address 1�?7 r=.#S+a., c]"" ''+. ` ,.. Phone ity Contractor's Name _ -"Z^�/c/ License#29746k)" Business Phone IF3 Contractor's Address .�f • L'2'J.A,/df � .h+F1'•'w nr. ,.-+.^, t: s*�(w° Emergency Phdde/^ Is Certificate of Workman's Compensation Insurance on File With SJLHDI Yes—yC.pL No TYPE OF WORK(CHECK): NEW WELL❑ , DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ 1 REPLACEMENT DISTANCE TO,NEAREST: , Septic TankSewer LinesPit Privy,— Sewage rivy,Sewage Disposal FieldCesspool/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 11 DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge Of Casing ❑ IRRIGATION r ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seat Installed By: PUMP INSTALLATION: Contractor Type of Pump •yH+.P. r PUMP REPLACEMENT: 10 State Work Done�'Z+Q N�1[9,.F .rf� J/^!/f�,�(/ PUMP REPAIR: ❑ State Work Done �3TRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' I will r a Grout Inspe' n r to grouting and a final inspection. Signed X __ Title: Date: (Draw Plot Plan on ReArse Side) a , PHASE i FOR DEPARTMENT USE ONLY _ ��(� �� Application Accented By 1\\ \ � Date J=LXX Additional Comments: I!:— .Phase I.Phase II Grout Imspe often 1 Final Inspeetlo Inspection By Date Inspection By Date&,Ak.�.r/ Fat Is Due:11 ANNUALLY 13 PER UNIT 0EP SITE . ❑EACH ❑ January,t a R O By January 31 C3W July t a Receed By JWy 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT AMOUNTOUE CHECKED ' I GATE DATE REMITTED AMOUNT ' FEE 4T - ` O LESS PRORATION PLUS PENALTY OTHER 1 i _....... OTHER - l/r1 3 io�3� 1 oa L's bib by aN Receipt No. _ Permit No, Issuance Oat. Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL MEALTM PERMIT/SERvicEs 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON.CA 95201