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applications will orrmuerseu vvneI.aumnmea rroymq ..vu.y,mcv. ..c w ... .,.y.. ..... ^rr••- ••-••. FOR OFFICE USE: APPLICATION (For 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 n dcaqul oun��t )Ordin�a�ce�N�o.,1862-and the rules and regulations of the San Joaquin Local Health District. Exact Site Address'ssl.,,, V�/� .r/S�L_—/'] /- - City/Town f,"Torte(owner's Name "� 1 11A- I-! M Phone - A Address City g5 U Contractor's Name License BPhone-��e Contractors Address j 'Emerge cysines'Phor>q -f - - - •J Is Certificate of Workman's Compensation Insura on File With SJLHD? Yes C/ No TYPE WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ - DESTRUCTION❑ _ - -- - WEL lut-DRINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLkEMENT❑ -_ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit N Other _ Property Line Private Domestic Well Public Domestic Well - - INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well ExcavationVeK / DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - L.�- 01 ❑ IRRIGATION ❑l—I�/�`RAVEL PACK Depth of Grout Seal - ❑ CATHODIC PROTECTION MOTARY Type of Grout4- ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By Ad,- C PUMP INSTALLATION: Contractor Type of Pump H.P. y PUMP REPLACEMENT: ❑ Work Done PUMP REPAIR: f� SWte Work Done DESTRUCTION OF WELL: Well.Diameter Approximate-Depth Describe Material and Procedure. - I hereby certify that I'.have prepared this appiication and thai tt ie work 'will fbe 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 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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhidh this permit itiissiled, I shall employ persons subject to workman's compensation laws of California." eel lona Grout Inspection plsito if ng end incl inspection. SIgaW)( .-_- _. : ... Tide: Date; - (Draw Plot Plan on Reverse Side) - • ,iE� �FOR DEPARTMENT USE ONLY � �,. py PHASE 1 z/ Application Accepted By (,5j�4,e�� l .Date�� - o/ Additional Comments: Phase 11 Grout Inspection , / hase III Final Inspection InspectionBy9 al-� Date // '� T A4 Inspection By Date 10 -5'�dr Fee Is Due: I] ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January Td Recalved By January 31 ❑'-July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE . S. AMOUNT DUE CHECKED �a[ DATE DATE REMITTED AMOUNT FEE p{ LESS PRORATION -.- PLUS PENALTY OTHER OTHER Receive0 Dy Date Receipt No. �Permll No. Ilisuance Date Mated Delivered _ APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE..P.O.Bo.2009 STOCKTON,CA 95201