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:ICE USE: APPLICATioto Al Nan-Transferable, Re le e b PUMP&WELL -+ ENVIRONMENTAL H TH POR,N�.LT ttjj JJ 'TE IN TRIPLICATE) WATER QUALITY `� 11,ri[ed. oPay on is hereby made to the San Joaquin Local Health District for a permitto construct a 9ros�t th "orrA.lher m n is r f compliance w'th San Joa uin Count Ordinance No. 1862 and the rules ari�3 ul t r o� t quin cal Health District. y A .lite Address / �s H i0% own �fir's Name Phone ess C& City d� � /' _/ 1 7 itractor's Name License#g 13 J3 Business Phone h ntractor's Address Emergency Phone . � S r / I .Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No + TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION 13 �/ [J II WELL CHLORINATION ❑ WELL ABANDONMENT 62" OTHER ❑ PUMP INSTALLATION.❑ PUMP REPAIR IES ' REPLACEMENT C3 U{ it 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 0 ❑ INDUSTRIAL . ❑ CABLE TOOL Dia.of Wel! Excavation ❑ DOMESTIC/PRiVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information '1E ❑ GEOPHYSICAL Su ace Seal Installe By: / PUMP INSTALLATION: Contractor � Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done 00, PUMP REPAIR: E State Work Done - } DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe-Material-and-P-rocedure— -- ----- -- A 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 ruies 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 sub-contracting 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." 1 wrilli final Inspection. Signed X Title: //�` Date: on Rever Side) FOR DEPARTMENT USE ONLY PHASE I q Application Accepted By Date Additional Comments: -% A& ! Phase II Graut spec on Phase 111 Final Inspection Inspection By Date Inspection By Date Fee Is Dile: ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING T REMITTANCE $ AMOUNT DUE CHECKED DATE PATE REMITTED AMOUNT FEE LESS PRORATION PLUS `+ PENALTY J OTHER A'�� 8" OTHERCR -7q--tZ10 11 /s/ 7 Received by Date Receipt No. Permit No. Issuance Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiT15ERVICES 1601 E.HAZELTON AVE.,P.O_Box 2009 STOCKTON,CA 95201