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Applications Will Be Processed When Submitted Properly Complet a\19ogi plication. APPLICAT FOR oFUcE usE: _ (For Non-Transferable' Rev o pendable)B 19a� PUMP&WELL ENVIRONMENTAL HE PE fl f (COMPLETE IN TRIPLICATE) j33 ` �Ov �0 WATER QUALITY i �� L A) '+ O 9 1 -felO-1,S- ` ein described.This application is ' Application is hereby made to the San Joaquin Local Health District-fcf"a eermittoconstr /b las PP made in compliance with San Joaquin County Ordinance No. 1862 and the rules and r 1� �b"h an Joaquin Local Health District- Exact Site Address .2 Miles North of Front Street d City/Town Linden 501 R. of Duncan Rd. Phone f. Owner's Name Address �� - City Linden CY Contractor's Name License#�— Business Phone_ 887- 55 Contractor's Address _F-0- BOY bL`+} Linderi Emergency Phone € 8 -394 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No I � I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 11WELL ABANDONMENT 11OT ER 13PUMP INSTALLATION 13PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Line§ Pit Privy ` CesSpool7S e a e Pit Other Sewage Disposal Field � P 9 Property Line - Private Domestic Well 1 Public Domestic Well INTENDED USE _TYPE OF WELL - ?"y€- -� W El INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation.... W 4 ❑ DRILLED Dia. of Well Casing' T ❑ DOMESTIC/PRIVATE ❑ MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �J IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ r F { ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other!information - L ❑ GEOPHYSICAL Surface Seal Installed By: E. PUMP INSTALLATION: Contractor Type of Pump = H.P- _0ljMP REPLACEMENT: r ❑ State Work Done - --K - - E'Ul41P REPAIR: State Work Done --C ldhQz!a TintilS y f DESTRUCTION OF WELL: Well Diameter ! Approximate Depth Y ' Describe Material and Procedure i f 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. o Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for 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:1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensatiion laws of California." I will call for a Gr�t ection prior to grouting and a final inspect , k Signed X Title: �- ��'e�� Date: ( (Draw Plot Plan on Reverse Side) F RDE ARTMENT USE ONLY I PHASE I Application Accepted By Date Additional Comments: Phase II Grout inspection Phas til Final Inspection Inspection By Date Inspection By�_- Date Fee Is Due: EIANNUALLY PER UNIT +PER SITE El EACH' ❑ January 1 &Received By Jan July 1 R Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DA E DATE REMITTED AMOUNT f FEE i LESS PRORATION PLUS PENALTY OTHER OTHER ` n �Z �5�3 �(0 1 µ Dae Receipt No. Permit No. Issu nce Date Maiied Delivered Received by APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E:HAZELTONAVf=.,P.O.Box 2009 STOCKTON,CA 95201