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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. FOR a ICE usE: APPLICATION (For Non-Transferable, Revocable,Suspendable) !!! /��✓�G� ENVIRONMENTAL HEALTH PERMIT 6911I5i'4= PUMP"ELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit toconstruct and/or install thework herein described.This application is made in compliance�yit�h San Joaquin County Ordinance No. 1862nd the rules and regulations of the San Joaquin Local Health District. Exact Site.Address C� t /lJ/G A ul�j jE 1 City/Town 7C� yip Owner's Na a < f �- S' Phone Address City. -3 / Contractor's Name License# ��Z Business Phone ra - f(e 7 Contractor's Address-V.;�IQ d 4rgency Phone ®N Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION* PUMP REPAIR REPLACEMENT❑ � DISTANCE TO NEAREST: Septic Tank/®0 Sewer Lines/4149� Pit Privy /j 0 Nom. ' Sewage Disposal Field Cesspool/Seepage Pit 4l26JJe, Other 1(f 0 eV Q_ Property Line L? / Private Domestic Well B/L/ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation_. DOMESTIC/PRIVATET- ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC y ❑ DRIVEN Gauge of Casing - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal c_!Y� e-ye—_ y� ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL S rface Seal Installed E PUMP INSTALLATION: Contractor " d G Type of Pump H,P. Zwola ILZ 1&2- 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." IVI call for a Grout Inspection prior to grouting and a final inspection. Signed X - Title: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By C) Date Additional Comments: Phase II Grout Inspeclio pt►ase I_Fipal Fnspection ��-��-brl Inspection ByT�, �� > Date Inspection By �� / Date Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JanGary 1 &Received By January 31 ❑ July 1 &faeceived By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED FEE AMOUNT �s Y�� a LESS PRORATION PLUS PENALTY OTHER OTHER � !a 36 Yr Rl ,,,td by Date m I Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES--T-Q,- ~ENVIRONMENTAL HEALTH PERM IT/SERVICE_St , 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .- ji