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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 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 District fora permit to construct and/or install the work herein cfescribed. This application isA made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address D (...s:::\ . lA/WSEi\-i City/Town -I" Owner's Name ±t)__D -.C)--C-C-- Phone Cdr2i5- ---) ci ? -1 Address ___5:5 C1 (.>I City h ODrSt Contractor's Name 1-k E•ovn )bs Ta,,License # ).5S:63.3 Business Phone Contractor's Address 35p..5 ?VA-N•)WI Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ."( No TYPE OF WORK (CHECK): NEW WELL rrg) DEEPEN 0 RECONDITION El DESTRUCTION 0 WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION 0 PUMP REPAIR 0 REPLACEMENT 0 DISTANCE TO NEAREST: Septic Tank /06 -4- Sewer Lines Pit Privy Sewage Disposal Field /00 Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well TYPE OF WELL CABLE TOOL DRILLED DRIVEN ka GRAVEL PACK 17.1 ROTARY OTHER Other INTENDED USE INDUSTRIAL IN DOMESTIC/PRIVATE DOMESTIC/PUBLIC IRRIGATION CATHODIC PROTECTION DISPOSAL GEOPHYSICAL PUMP INSTALLATION: Dia. of Well Excavation Dia. of Well Casing Gauge of of Casing _iii;a1L-11. n Depth of Grout Seal 5CI - Type of Grout (.7cs Lk Other Information Stfia y t..x.)01.7- Q Surface Seal Installed By: SaimItEMIptitalaktaaigii ILP Contractor Type of Pump H.P. -0 3st,) PUMP REPLACEMENT: PUMP REPAIR: DESTRUCTION OF WELL: Signed X 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 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." will call for a Grout Inspection prior to grouting and a final inspection. Title: \J Date: 0.06 (Draw Plot Plan on Reverse Side) Li State Work Done State Work Done Well Diameter Approximate Depth .SZ1Describe Material and Procedure CA FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Additional Comments Phast* Grout Inspection Date )1c3\ (60 Inspection By • Li EACH 0 January 1 & Received By January 31 0 July 1 & Received By July 31 rcu io kl.4C. &-..1 nr.14,,-,_, , BASE ... . .-. • ...... — - EXPLANATION — BILLING DATE REMITTANCE DATE S REMITTED AMOUNT DUE REMIT CHECKE0 AMOUNT FEE 4 L-L3 LESS PRORATION ei. ..... , A. 1,..;q1LA.AalerA ....- i A ..:••• . . , 1 t • PLUS PENALTY —. 0 lk II .4. / OTHER I • OTHER Date Inspection By iArdtIbia.111.3.01111111 Inspection Date criii 80 5 Receipt No. Permit No APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES Issuance Date Mailed Delivered 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 55 *f Rece,ved by