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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ; FOR GFFICE APPLICATION (For Non-Transferable, Revocable,Suspendable) - PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is qqq made in compliance with San Joaquin County�O/rdinance No. 1862 an he rules and regulations of the San J aquin Local Health District. Exact Site Address C/�►^ c� r-•. City/Town CCl t-11#1 Owner's Name X txA S- V` Phone _3 2I - Address 9, A 1.4- h P` City 40 r Contractor's Name ,r, tJ i'Ck &14? ,r�y�` i ti cense#_?`! �3 Business Phone 3 (c, 9 - f (-7 E Contractor's Address&4000 N, 10% tV. ISS + 14C0 Emergency Phone ! !a 17112_ 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❑ REPLACEMENTD � 1 DISTANCE TO NEAREST: Septic Tank �lLJ$ Sewer Lines ll>0 A/0. Pit Privy _Udt✓y Al C__ �I } Sewage Disposal FIR Id C— Cesspoo Seepage Pit 40 ,A G�� Other_ /v � LkJ Property Lin lJ• "-Private Domestic Well public Domestic Well INTENDED USE TYPE OF WELL d ❑ INDUSTRIAL CABLE TOOL Dia.of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t� j ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal p� ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor PAOV C�+ r ZP S&v-Vl CC Type of Pump e-r m O 41' H. I 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 appilication 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. Homeowner 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." y 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." YJ I�call Grout section prior togrouting and a final inspection.Signed X _ G-f �, Title: Dale: T (Draw Plot Plan on Reverse Side) % 70OR D7e, TMENT USE ONLY PHASE ? Application Accepted By ' ` Date y Q Additional Comments: PhaS I Grout spection 11 mal INS ction Inspection By Date ' y Inspection By e t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 5t PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION REMITTEDAMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT '4 FEE LESS PRORATION PLUS - PENALTY OTHER « l OTHER s r-N, gO Received by bate Receipt No. Permit No. Issu nce Dae - Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601;E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201