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Applications Will Be Processed When Submitted Property Completed.Be Sur ``vv11 11t�� 1�5 V - FOR .fFICE USE: - p t w SIA TReQpplicatfon,L APPLICATION , P _ (For Non-Transferable, Revocable,Suspendable) APR 9 1981 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) � WATER QUALITY SAN JOAQUIN LOCAL Application is hereby made to the San Joaquin Local Health District fora perm itto construct and/or install the work herrei Dscbed This application is made in compliance with San Joaquin County QRrdina ce N 1862 and the rules and regulations of the San Joenuin Local Health District. ess Exact Site AddrV (�..J f-71- I CltyfTown l r Owners Name Ll esN C M �•� ' Address - Phone ContractoYs Name A p y City License k/ 3a 63 Business Phone Contractor's Xagyd Sznc. fc]"aw ✓a L 6 Emergency Phone - ? r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - l TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS REPLACEMENT(& DISTANCE TO NEAREST: Septic Tank Sewer Lines 1170 Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other ` Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ; I INDUSTRIAL ❑ f CABLE TOOL DID. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing dW DOMESTIC/PUBLIC ❑,DRIVEN Gauge of Casing ❑ IRRIGATION 0-RAVEL PACK Depth of Grout Seal i ❑ CATHODIC PROTECTION ❑ ROTARY 11 DISPOSAL 11 OTHER Type of Grout ❑ GEOPHYSICAL Other Information PUMP INSTALLATION: Contractor Surface Seal Installed By: j Type of Pump H.P. 3 j PUMP REPLACEMENT: Q$ State Work Done p_,." .t-4" PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter J Describe Material and Procedure Approximate Depth - 42 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County nr- ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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 certity 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 calf for a G t Inspection prior to grouting and a final Inspection. i Signed X air y� y'^�yy-JIJ 11411 --1 Title: ( Date- (Draw Plot Plan on Reverse Side)� r\ *_4A h y FOR DEPARTMENT USE ONLY PHASE I Application Accepted By SI Date Additional Comments: .� Phase II Grout Inspection Ph III Final Ins f Inspection By _�Qc Date 11 Inspection By��;� _ / Date Date s F!!IS Due:0 ANNUALLY 11 PER UNIT 13 PER SITE 13 EA ❑ Janue 1 a Recelved B Januar 31 F ' N Y Y [01 July 1 8 Repeive0 aY Jul 31 BASE EXPLANATION BILLING REMITTANCE s REMIT DATE DATE REMITTEp AMOUNTOUE CNECKED FEE [z AMOUNT r LESS 4 P PRORATION PLUS PENALTY OTHER 1 OTHER 60733 Received DY Date >• RKc&Pt NP. Permit No I u nco Dete Ma I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERW CE9 DelNered a...l. t01 E.H ELTON AVE,P.O.ba f,, STOCKTON,CA 36fet ;�r�