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_ Applications Will Be Processed When Submitted Propeny wmpletea.oe ourv, r u area -row mvP FOR OFFICE USE: APPLICATION 1� (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 San Joaquin nC�County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address W.4, r f{t. /!� S -4e-I/A.14a- City/Town Owner's Name Phone Address m o City Contractor's Name License#&.Ll 73 Business Phone 3 6 3 Contractor's Address I Emergency Phone 471(-6-F& .lJ" Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 43 PUMP REPAIR❑ REPLACEM ENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �❑3 DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing J9 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ^ /7 Surface Seal I stalled By: PUMP INSTALLATION: Contractor Type of Pump / —z" H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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 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 wp all r a Groutapectlon Vor to grouting and a final Inspection. Signed X / r4L7life: Date: ^/ 4--�� �� (Draw Plot Plan on Reverse' ide) FOR DEPARTMENT USE ONLY p PHASE I ^ L1 'tjlp0 Application Accepted By N J - Date Additional Comments: Phase 11 Grout Inspection Phase 111 FI al spec: Ion Inspection By (1(1 1�_ Date Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receive y January 31 ❑ July 1 d Received By July 31 EMIT BASE "fN:r CHECKED AMOUNTFEE LESS ^ PRORATION PLUS PENALTY OTHER OTHER Racelved by Data Receipt No. Pormtl No. leeuance D&e MaileC Del, ered 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON,CA 95201 -