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FOR OFFICE USE: s l Lkj'PPLiCATION I` JBIV 2 21, Non-Transferable, Revocable,Suspendable) PUMP &WELL -_ ENVIRONMENTAL HEALTH PERMIT ' n�[�n WATER QUALITY (COMPLETE IN TRIPLICATE) � - �, C(`� * t. 7i Application is hereby madetothe an alq�ulinl7' I � iht)istrictfor,apermittoconstructand/or install the work;herein described.Thisapplicationis made in compliance w' h.San J quln ounty.Ordinance No. 1862 and the rules and rtp llatlons of the San Joaquin Local Health District. Exact Site Address oU - Cit'% own -- 1 Owner's Name Phone ' _ Address C CSY�; . .>; City— - — Contractor's NameLicerise Skyvv1C)48 Business Phone ckck — EmergencyP ne 4wa7:14 L� -Contractor's Address 5_N Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ` TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN Cl RECONDITION DESTRUCTIONO WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 6 REPLACEMENT❑ < DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy - Sewage Disposal Field _ Cesspool/Seepage Pit r Other.___ Property Line _ Private Domestic Well Public Domestic Well- INTENDED ell_INTENDED USE i TYPE OF WELL ❑ INDUSTRIAL13CABLE TOOL Dia. of Well Excavation - -- — I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - — ❑ DISPOSAL ❑ OTHER _ Other Information -- ❑ GEOPHYSICAL 4 Surface Seal Installed By: - - PUMP INSTALLATION: Contractor_ �� C C: riL _ -- Type of Pump H.P. PUMP REPLACEMENT: E State Work Done PUMP REPAIR: , State Work Done — -- / - DESTRUCTION OF WELL: Well Diameter - Approximate Depth ---I -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 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 pe ons sub"ect to workman's compensation laws of California." 11 c for a Grout Inspec In rior t routing a final Inspection. Signed X Title: - 'Date: (Dra of Plan on Reverse Side) -_ - - .d r FOR DEPARTMENT USE ONLY PHASE Application Accepted By - - `^�'" Date ,�� Additional Comments: Phase)] Grout Inspection I Phase III Final Inspection / Inspection By— ._/_Q� Date _ Inspection By Date 2-1___ ` Fee Is Due: 11ANNUALLY - fff❑ PER UNIT ❑ PER si rE ❑ EACH ❑ January' &Received By January 31 El July 1 &Received/Ry July 31 �.- - - — �R" REMIT BASE I. EXPLANATION BILLING REMITTANCE 3 - AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE - LESS' PRORATION - PLUS PENALTY - OTHER THER C)9 Received by Dale Receiot No - Permit No I�suance to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bocx 209 STOCKTON,CA 95701