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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OSr'ICE USE: APPLICATION ' ! 3 (y (For Non-Transferable,Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT / (COMPLETE.IN TRIPLICATE) (g(o(sWATER QUALITY -�4{CCPp ,,�� _ QUALITY Loca aalthol �71�w,,,,� �d•' (6 fIllk pplication is hereby made to the San Joaquin stricfor a permit to construct and/or installthework herein described.This application is ade in compliance with San Joaquin County Ordinance No. 1662 and the rules and r la ral rt� ii. Lit j He th District. ,act Site Address � y��Cs� et,,Qa �...:� ....�.,.,/ ._ i�al� ity/TdNn �- Owner's Name �.der.av Phone �gie t �ddress /21H t� �� .P � City � 3 . ontractor's Name�� r'OtY (�lL LCirea License#2 99fi�o8' Business Phone �C4� 7y� J o Contractor's Addressy tin AM SIP - Emergency Phone�'gy rr^ -f n ()`t 'F Certificate of Workman's'Compensation Insu ce on File With SJLHD? Yes —/ No rYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO.NO WELL CHLORINATION El WELL ABANDONMENT 11 OTHER 13PUMP'INSTALLATION LT PUMP REPAIR❑ I REPLACEMENT❑ ;A �I STANCE TO NEAREST: Septic Tank Alp Sewer i es Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 77, Private Domestic Well Public Domestic Well ' INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation eDOMESTIC/PUBLIC OMESTIC/PRIVATE ❑ DRILLED - - Dia. of Weil Casing DRIVEN Gauge of Casing RIGATION ❑ GRAVEL PACK Depth of Grout Seal ATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ,❑ GEOPHYSICAL Surface Seal Installed By: _ PUMP INSTALLATION: Contractor Type of Pump S,4 g H:P:e"'3 - 7 oQ PUMP REPLACEMENT: ❑ State Work Done 'PUMP REPAIR: ❑ State Work Done ` I 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 abcoYdanCe with San Joaquin County ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. _ ' Home owner orlicensed agent'ssignaturecerlifiea the lollowing:"I certify that in the performance of the work forwhich 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 for which this f permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call a ,routlJ eelion Nor p groom d a final inspection. L . 'Signed X `-� � Title: A� �//Date: S I - (Draw Plot Plan on Reverse Side) ' ^�FOR DEPARTMENT USE ONLY PHASE I -P T�0 Application Accepted By Date ' Additional Comments: r e P as 1 Grout inspection rn�e�C�r+k��aY�P�t•OvOY spm Phase Ill Final Inspection Inspection By Date S`.-l�41 Inspection Bye% G'e� Date C L7 ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1&Received By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE '60 0 0 - 1 LESS �(f �. G.(./We aNay� cY P CZ _ CJ Lie— r PRORATION PLUS a r+ , ' PENALTY J,. _ L v,,;w, �:O?HER d� (.i e.!I OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered _9 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201