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Applications.. ill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION w � s (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) ----WATER QUALITY 2[a 9 ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application ism' made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulati2_WRM n Joaquin Local Health District. Exact Site Address t 1�J C 1YA0A�i5&(�� /4 /�!GCity/Town Owner's Name lam t)[��. _ Phone Address .0. .o. - City J^/� � Contractor's Name _CALAAAW ©P/LLJ&!T C&_ License#,g21AT!2 BusinessPhone Contractor's Address t?Q 1 S,IM'K1L�Uu rU�er�� Emergency Phone Is Certificate of Workman's ComperiRat ion In-gi irAnce on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ l� DISTANCE TO NEAREST: Septic TankSewer Lines Pit Privy I Sewage Disposal Field le),O- Cesspool/Seepage Pit Other Property Linel.9771-7-Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation v 1i DOMESTIC/PRIVATE I 13 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (.CC ❑ IRRIGATION GRAVEL PACK Depth of Grout Seat u�_�� '�; 13CATHODIC PROTECTION `� ROTARY Type of Grout A� 11DISPOSAL ' ❑ OTHER Other Information Q ❑ GEOPHYSICAL Surface Seal Installed By: r� PUMP INSTALLATION: Contractor i Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done IN . 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:1 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." r, 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 eimploy persons subject to workman's compensation laws of California." I will call loi a Grout Inspection prior to grouting and a final inspection. I`. Signed X Title: —�2(4 _- Dale: 11 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date Additional Comments: Phase 11 Grout Inspection hale Ill Final Inspectiont Inspection By Date Inspection By ate f aZ C'P Fee Is Due: El ANNUALLY El PER UNIT LJ PER SITES ❑ EAC ❑ J4h uary 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE I� LESS PRORATION PLUS PENALTY y OTHER I� yIII � OTHER II i 14J 1—79 I� - Received by DafeIyII! Receipt No. Permit No. - Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES!rTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P-O-Box 2009 STOCKTON,CA 20 Y yp ']