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NPPllcatlons Wltl Lie rrocessea ;;nc•n auon,lecea i•r��s=r:t 4 ainPi eu ov cure a yrl t iG ,,N Ic xlc�l,. FOR OFFICE USE: /4PPLiC,<1TlQiV Non-Transferable, Revocable, Suspendat-Z"�-.; -�- -- 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 No. 1882 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 1474 • Thornton Rd. _ City/Town 7 Owner's Name Phone Address City Contractor's Name�Zei? License#!22 5%4 Business Phone_� � Contractor's Address _= / - _- Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION$a PUMP REPAIR❑ REPLACEMENT El 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 !1 � ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation.._ --w. ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ; I © IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ ------- CATHODIC PROTECTION ROTARY Type of Grout V-L 7-6 - ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: i ' rim- %TQ r� PUMP INSTALLATION: Contractor ? �'�� _ Type of Pumper �2--Y' s:: J 1 - - H.P. - -- PUMP REPLACEMENT: ❑ State Work Done --- PUMP REPAIR: ❑ State Work Done ---- - DESTRUCTION OF WELL: Well Diameter Approximate Depth mm Describe Material and Procedure I I hereby certify that I have prepared this application and that the work will be done ir•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." 1 will call for a Grout Inspe ion prior to grouting and a final inspection. Signed X7 Title: � Date: Y z Z31 _._/ . ` (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI &L Application Accepted By - �`-'1 Date �� Additional Comments: --- Phase It Grout Inspection ,,,Ph se III Final Inspection s Inspection By Date Inspection By Date `-'� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By anuar 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REWT BASE EXPLANATION AMOUNT DUE CHECKED PATE GATE REMITTED AMOUNT FEE LESS - PRORATION i PLUS PENALTY OTHER OTHER Received by 1 Date Receipt No. ':fermi;No. Issuance Date Mai$ed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 _