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.. --.. .. . .. FOR OFFICE u NUG 3 u APPLICATION IC,AQUIN L r Non-Transferable, Revocable,Suspendable), PUMP&WELL piI u�pL-I,ti� R,CV�NVIRONMENTAL HEALTH PERMIT (M-PLETE IN TRIPLICAXT WATER QUALITY Application is hereby made to the San Joaquin Local hDia rict fora permitto construct and/or install the work herein described.This application is made in compliSnce ith San Joaym County Ordi a Le No. 1862 and t e r es nd egulations of the Sar1Joaqu. Local Health District. Exact Site Address 1^ `f' v City/Town �'� Owner's NameP✓ �' ` ` Phone bio Address 12 9'9 r /0t/ J , aer XzaCity Contractor's Name },f-^ License k/V 3 Z C. Business Phone 7 se S y7 O Contractor's Addre � S' � S.�p !6 W L Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes &. No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ME WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank A Sewer LinesyC Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property LineVQ.Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL , A, ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation/ ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing WrRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY - Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL -T-�-� Surface Seal Installev By: PUMP INSTALLATION:- Contractor l.Jw �' �✓e�,-4,Ja Type of Pump L s - H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth - Describe Material and Procedure � L 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 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." �I aw.�ill call for as Grout Inspeectiion1-Z®prior to grouting and a final Inspection. r Signed X il. y J✓ --�+'�'� Title: 6�L�, ® Date: Zv. l (Draw Plot Plan on Reverse Side) - - FOR DEPARTMENT USE ONLY PHASE I rT _ _ Application Accepted By �+�+v�^+,_ Date Additional Comments: ~ W 1 Phase II Grout Inspection hase I F Ins Ito �� Date Inspection By tee Inspection By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. I suan Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201