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_ ,QF '--E usE: APPLICATION % (For Non-Transferable, Revocable, Suspendabl PUMP&WELL ✓" v 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 r Inan N 1862 and the rules and regul/atio s of then Joaquin Local Health District. Exact Site Address LSJ CJ[ �Q.v ��.1 'K, mi Se �'+ I n Owner's Name Phone EL77 Address City Contractor's Name ! License# Business Phone C Contractor's Address 50 ' � Emergency Phone ^ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT El DISTANCE TO NEAREST: Septic Tank I4 Sewer Lines c< � Pit Privy Sewage Disposal Field /D[Zl _ Cesspool/Seepage Pit - Other Property Line, Private Domestic Well �5oLZ-f` Public Domestic Well INTENDED USE TYPE OF WELL �r ❑ INDUSTRIAL &CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ff� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casings IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ll ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL r Surface Seal Installed By: PUMP INSTALLATION: Contractor rJ V aL LIC - Type of Pump _ =.I�I r i0 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:1 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." I will call for a GoutIn pectio to grouting and a final inspection. ��/rr�,�, t v� Signed X ? Title: 3 d2 Date: i� (Draw Plot Plan on Reverse I ) FOR DEPARTMENT USE ONLY r PHASE I Application Accepted By W�j" Date`1011A"� Additional Comments: Phase II Grout Inspection PhasA III Final Inspection Inspection By uc Date Inspection By-W, — Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Ja uary 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEEt W01 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No Permit No. Is uance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201