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f Applicatlons Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. j FOR OFFICE USE: APPLICATION (For Non-Transferable,Revoeeble;5uspendable) PUMP&WELL i 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 t made in.compliance with San Joaquin County Ordtnan e N .t862 and the rules and regulations of the San Joaquin Loyal Healtph District. f Exact Site Address L City/Town Owner's'Name 01,11 con 6 Phone Address d rti. City - ' e,, w i Contractor's Name Flo-d 1�f,,DJ E= License# 447-5 2?16 Business Phone ` Contractor's Address - �'%r 4. Emergency Phone r' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW W — ❑ RECONDITION❑ DESTRUCTIO I l WELL CHLORINATION❑ W L ABANDONMENT -OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ -� REPLACEMENT❑- r DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy [ Sewage Disposal Field_ Cesspool/Seepage Pit Other Pro-party Line Private Domestic Well Public Domestic Well i INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE-TOOL Dia.of Well Excavation - DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing LIC ❑ DRIVEN Gauge of Casing 1 ❑ IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal ' ❑ CATHODIC PROTECTION ❑ ROTARY T i ype of Grout f 4 ❑ DISPOSAL_ © OTHER Other Information 1 ❑ GEOPHYSICAL R Surface Seal Installed By: t PUMP INSTALLATION: C'Ontrt[Utor fiype of Pump. H.P. _ PUMP REPLACEMENT: -+- d State Work Done - ,... PUMP REPAIR. ❑ State Work Done DESTRUCTION OF WELL:. : iWell Diameter 1/ Approximate Depth CP Describe Materia;.and Procedure t .. L f�Sl q #) t ) . I hereb 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. it i I Homeowner or lidensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit T is issued, I shall not-employ any person in such manner as to become subject-to workman's compensation laws of California." 4 Contractor's hiring or sub-centracling 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." "`q+ i will call forp Grout spection prior It routing and a final Inspects �t Signed X Title: & &A A' �.L Dale: "r (Draw Plot Plan on Reverse Side) ) FOR DEPARTMENT USE ONLY PHASE i Application Accepted B Da le7�_ Additional Comments' Phase II Grout nspection a ase Fitiaf Inspectlon �� i Inspection By Inspection By ¢ Date +f • Fee Is Dile:❑ ANNUALLY ❑'PER UNIT '❑ PER SITE ❑ EACH:` ❑ January1'&Received By January 31 '❑ July 1&Received By July 31 7I i BILLING REMITTANCE: S REMIT • BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKS) AMOUNT -: FEE ._ QIO OV LESS _ PRORATION FF PLUS - PENALTY 1' 3 OTHER �u ;{. 4' t S OTHER Received by Date --Receipt No. - Permit No. - .-. ._J.lssu nce O to .Mailed- Delivered ,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160t E.HAxELYON AVE.,P.O.Box 2069 STOCKTON,CA 95201