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FOR OF"ICE USE: APPLICATION %SW(For Non-Transferable, Revocable, Suspendabi Noll 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 San Joaquin County Ordinance N 1862 ar/�/d the rules nd r u_lat o s of a Si JOa ocal Health District. Exact Site Address /�..Z G . Ai 111Lt�CP� %t/7tL..41 A !/ l�ida1{ jot �pjoli, Y_fi Owner's Name o ////// Phone _� Address {p .S � City Contractor's Name �._alicense# �29�R/� Business Phon �J Contractor's Address 1.a_ S ,�/0�'��lergency Phone .��W Z/ Is Certificate of Workman's Compensation Insurance on/File -With SJLHD? Yes k No TYPE OF WORK (CHECK): NEW WELL{ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ / -J DISTANCE TO NEAREST: Septic Tank 150 Sew'pr Lines Pit Privy Sewage Disposal Field /.Jr Vs. Cesspool/Seepage Pit _ Other Property Line - Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL rr 0J II NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑n,DRIVEN Gauge of Casing 11 IRRIGATION I RAVEL PACK Depth of Grout Seal 11 CATHODIC PROTECTION ;ROTARY Type of Grout /ss iQJ ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ! G\ PUMP INSTALLATION: Contractor Type of Pump H.P. N PUMP REPLACEMENT: ❑ State Work Done _ PUMP REPAIR: ❑ State Work Done R� DESTRUCTION OF WELL: Well Diameter Approximate Depth _ Describe Material and Procedure 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 sub-contracting 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 wi{t/�Jc''allpfo'rpa Gmrout ns on prior t grouting and a 1 al in Ion. Signed X � pC ey�'r71 Gill / d Date: Aw ({ ( raw Plot Plan on Reverse Side 7 JS W 0J-4 ARIL IED V rT FOR DEPARTMENT USE ONLY PHASE OST PFrC✓1i; r KYFTER TEf.�G'O ry W�ThFH{.TN .D/r.{O FD,e. � NioSS�hv Application Accepted ByDate Additional Comments: Kase II Grout Inspection Phase III Final Inspection Inspection By Date /6111 / Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE 5 BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER rI- �u S 11 o -T Rectilived by I Dale Receipt No. Permit No. las ante Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201