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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION r (For Non-Transferable, Revocable, Suspendable) ' 10 PUMP&WELL ENVIRONMENTAL HEALTH PERMIT - (COMPLETE IN TRIPLICATE), .x'�~ WATER QUALITYy ¢ Y Application is hereby made to the SanJoaq lLocal Health District for apermit toconstructa o/or install the work herein described.Th israppli cation is i made.in compliance wrriit�th n Joaquin Coy my Or inance No. 1862 and the,rules and regulations of the San Joaquin Local Health District. Exact Site Address o^ City/Town 14 ea rw _ Owner's N&ne L e Ina -/ns Y�_- . Phone_� v� 7 7e9-- Address e9 ..Address 607.81_le.-SO-11i Contractor's'Name License#r�9�353_� Business Phone�3/rte q ��77 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes )4— No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION0,; DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATION52. PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank f Sewer Lines` Pit Privy Sewage Disposal Field_ t" I'..+t Cesspool/Seepage Pit /dd Other Property Line Private Domestic WellPublic Domestic Well INTENDED USE TYPE OF WELL © INDUSTRIAL V..QABLE TOOL Dia. of Well Excavation .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 7" ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ yGRAVEL PACK Depth of Grout Seal ❑ CATHODI 6 PROTECTION �_� ❑ ROTARY-';!" Type Type of Grout H ❑ DISPOSAL, ❑'OTHER Other Information I ❑ GE=OPHYSICAL Stirfa a SQal Installed By: V�!l or PUMP INSTALLATION: Contractor 12411z--y ��tµ t to rp T Type of Pump ;7 7A H.P. PUMP REPLACEMENT: ❑ State Work Done { PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth { R Describe Material and Procedure 1 ' � p 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'owne'ror licensed agent's signature certifies the following:"I cer-ify that in the performance,of the work for which this permit is is ed, I shall'ri ploy;dr�y,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." 1111WIII all I a Grout�lnspection prior t\o grouting and a final inspection J t'C / S. Date: Signed X��. � _ __ �� Tlile: � �jep 3 (Ara-w_RJot P' on Reverse ) FORrDEPARTMENT U ONLY PHASE tl .--' Application Accepted By B r Date Additional Comments: as 1 Grout Inspection�•/.,u ! �3 l Inspect' ,,_,Inspection By Date_ l r 0:1. Inspection By Ph III FinaDate `� V �� F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE © EACH i0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT a BILLING REMITTANCE $ BASE EXPLANATION �t� AMOUNT DUE CHECKED 1 DATE DATE REMITTED AMOUNT f► t FEE LESS PRORATION PLUS ;_ T , PENALTYi OTHER 1 - �DTHER g 'ceived iby - Dale Receipt No. P rmit No. rissuaAce Date Mailed. Delivered 4PPLICANT--RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2011 .STOCKTON,CA 95201 .F