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Applications Will Be Processed When Submitted Properly Completed.Be Surign The Applkatlon. UU FDR o1 FICE USE: APPLICATION MAR 26 1981 (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL MPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT PI ication 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 y O made in compliance with San Joaquin Countrdinance No. 1862 and the rules and regulations of the So aquin Local Health District. Exact Site Addresns.....I g I W r' foZO City/Town _ G/,LCQ •.� Owner's Name T —7,290 - 1 Address 11717 Lr Il wa„ ,Zp Phone I _ Contractor's Name b f SF1/cJ � License to�!I9l1/n�` Business Phone — Contractor's Address ;45436 . )Jo ii r T es y Emergency Phdne Is Certificate of Workman's Compensation Insurance on File With SJLHO? YesNo _ TYPE OF WORK(CHECK): NE`W WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ - - WELL CHLORINATION ❑ - WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR O -- I REPLACEMENT - DISTANCE TO,NEAREST: Septic Tank Sewer Lines - __ __�_- pit Priyy 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 o ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 13 DISPOSAL t ❑ OTHER Other Information 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump PUMP REPLACEMENT: 10 State Work PUMP REPAIR: ❑ State Work RUCTION 00 Op WELL: Well Diameter Approximate Depth Describe Material and Procedure s I 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 subcontracting 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 s"r a Grout Inspe n r to grouting and a final inspection. Signed X Title: Date: (Ora Plot Plan on ReJ6rae Side) i FOR DEPARTMENT USE ONLY PHASE I A• nom Application Accepted By. ' ?,\Y`\t\W11, Date?VI Additional Comments:_( .Phase II Grout inspection 1 Final InIapecllo Inspection By__-(�1�_. Date Inspection By Date B . Fee 18 DUs:❑'ANNUALLY ❑ PER UNIT 13 PER SITErr ❑EACH ❑ January.l a R vad By January 31 ❑Jvly 1§Received ay Jmy ht BASE EXPLANATION BILLING REMITTANCE § REMIT DATE GATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE O^ 4 d LESS PRORATION PLUS PENALTY OTHER i . _.__........ OTHER RiKeived M _---- are Receipt NP. _ P.'r No Issuance Dat¢. .. Mailed Delivered. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 18111 E.HAZELTON AVE.,P.O.Sax 2M STOCKTON.CA 9=1