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- b, I� Applications Will Be Processed When SuAPPLICArly TIONCompleted. e eBe y FOR OFFICE USE; IM PUMP&WELL (For Non-Transferable,Revocabe,Supndable} k ^ I� ENVIRONMENTAL HEALTH PERMIT II WATER QUALITY (COMPLETE IN TRIPLICATE) 6 Application isherebyimade tothe San JoaquinLocalHealthDistrictforapermittoconslructand/orinstallthework.hereindescribed.Thisapplicationls t made in compliance,kkwith San Joaquin County Ordinance No.1862 and the rules and regulati ns of the San Jo qOl iLocal Healih District. Exact Site AddressI 11333 Golfview "Rd. J I Phone. 477-7307 Bus. � Owner's Name Mr• Tan Bryson to kt 2329 � Otto - �L t city - Address � ,' I Contractor's Name IM moOrman r S' Water stE'M5 License# 6�6 Business Phone • Emergency Phone, Contractor's Address 21.20 No } Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X t�1 TYPE OF WORK (CHECKJ: NEW WELL�K DEEPEN ❑ RECONDITION❑ DESTRUCTIONy� 7' N-❑-s-�--sWEL•L.ABANDONMENT ❑. .--OTHER ❑� -»•-PUMP•1NSTALLATION�/ PUMP REPAIR❑ y – WELL CHLORINATION J REPLACEMENT❑ '' iGb Pit Privy L N. Sewer Lines DISTANCE TO NEAREST: Septic Tank J O cesspool/Seepage-Pitther•– Sewage Disposal Field- _ _ V� Lin -77 tiWll Public Domestic-Weill .. Property Lin —Private Domestic Well l INTENDED USE TYPE OF.WELL 'i. 11CABLE TOOL— *Dia.of Well Excavation ❑ INDUSTRIAL.1- f PC ❑ DRILLED Dia. of Well Casing111 I'de DOMESTIC/PRIVATE f i 11 DRIVEN s Gauge of Casing } 410 ❑ DOMESTIC/PUBLIC '-Ti - ❑ IRRIGATION I IH GRAVEL PACK Dep h,of Grout`Seal _ Type of Grout`'( ❑ CATHODIC PROTECTION �OTARY r .I . ❑ DISPOSAL I ❑ OTHER Other In + Surface Seal.Installed By: 11 GEOPHYSICAL MOOT ori{a�,.wWater Systems PUMP INSTALLATION: Contractor H P 3 Type of Pumpr submersible .-. PUMP REPLACEMENT: 11 State Work'Done I I i PUMP REPAIR: ❑ State Work,Done c I1. Approximate Depth Well Diameter ` DESTRUCTION OF WELL: I*4s S, Describe Material and Procedure [ - I hereby certifyf that,I have prepared this apjilication and that the work will'be done in accordance with San Joaquin County Ilkordinances, state laws, and'rules and'regulatlons of the San Joaquin Local Health District. ` Home owner or-licensed agent's sis nature certifies the to "I certify that-in the performance of the work for which this per is issud, 1 shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting sighature certifies the to "I certify thatn the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of Calitorn%t' I� I will tail 10,1 a Grout Inspection prior to grouting and a final inspection Title: ;_, L Date: Signed X I�. (Draw Plot Plan on Reverse Side) t L. paw- I4 �a� FOR DEPARTMENT USE ONLY 9 11111!!1 Or PHASE I . j � III Date Application Accepted By , e , Additional Comment T1s•. io a ro In c n 1N Date Inspection BY Date Inspection By �� v•� ' ❑ Januar 1 &Received By'January 31 © du4y 1 &Received By Suly 31 Fee Is DuE: ❑ ANNUALLY ❑ PER UNIT , ❑ PER SITE ❑ EACH y REMIT I I` BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATIONDATE DATE REMITTED AMOUNT FEE LESS JN a PRORATION y s i PLUS PENALTY IiI _ d OTHER ('? OTHER 2) IL-W !@ Permit No, Is ante Da a Mailed Delivered Received by Date Receipt No. AL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENT