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FOR OFFICE USE: APPLICATION r'For Non-Transferable, Revocable,Suspendable •-: ' �L PUMP&WELL f ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) �.I41r ., WATER QUALITY � Ul Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the ork herein described.T is application is 0 made in compliance wi San Joaquin y Ordinance N . 1 2 of d the vs. n regui ti° oo�jh Joaquin cal Hea th District. Exact Site Address f/ it-9 Owner's Name JA Phone 771,Q Address CityL- Contractor's Name License#D?9D9/3 Business Phone Contractor's Address S/VEmergency Phone 6W-,0.2 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k-11No TYPE OF WORK (CHECK): NEW WELL W-urDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ©' PUMP INSTALLATION ❑ P REPAI0 D REPLACEMENT❑ 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 El DRILLED Dia. of Well Casing El DOMESTIC/PUBLIC ❑ RIVEN _ Gauge of Casing Gu lir IRRIGATION rrRAVEL PACK Y Depth of Grout Seal A e" ❑ CATHODIC PROTECTION [;,, ��Gttt40TARY Type of Grout 11DISPOSAL ❑ OTHER Other Information Q?.�Lll� ❑ GEOPHYSICAL Surface Seal Installed By: 4 PUMP INSTALLATION: Contractor Type of Pump 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 orsub-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 I tali for.a Grout ectlon prio to gr o tingp4J a final irispecti n: Signed X Date:d 11 �a �T (Draw Plot Plan on Reverse Side) 1 f R 2 us&;kk FO EPAfi1' NT USE ONLY PHASEI Application Accepted By2, Date ? �� Additional Comments: Phase 11 Grout Inspection haset tl Final Inspection Inspection By Date Inspection By ` Date Fee is Due: El ANNUALLY Q PER UNIT PER SITE ❑ EACH 13 January 1 &Rece . y January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE .EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED E AMOUNT FEE LESS II PRORATION I PLUS PENALTY OTHER OTHER ] `�/� ' o� 7 Z ( 70� —7 -13 S 1 Received by D.t& Receipt No. Permit No. Issua ce Date74 Mailed Delivered , APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201