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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION = -= (For Non-Transle aF ble,Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT _ I (COMPLETE IN TRIPLICATE)llj_22-a 1 E. ,PFJ"WATER QUALITY 22F,_7Cr7-0-Q 2- N I Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is (`J t made in compliance with San JoaquinCountyOrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. bb Exact Site Addressy--) n' ' . of lkycx 31)0 on V�� City/Town Owner's Name � �� o � 1 n}C�� Phone Address )c)+ r city + t f-57') C Contractor's Name r J r J Y r rJr License# l 3 Business Phone ��c`� 1 05 r\ Contractor's Address, l-flat en (1 &5tr) Emergency Phone _� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 7b TYPE OF WORK (CHECK): NEW WELL CJS DEEPEN ❑ RECONDITION 11DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank 76 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 1 j rr ❑ INDUSTRIAL 09 CABLE TOOL Dia. of Well Excavation t G11DOMESTiC/PRIVATE ®'DRILLED Dia. of Well Casing r+ r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / �C� �1,) ❑ IRRIGATION ®'GRAVEL PACK Depth of Grout Seal ,C�)1 ' © CATHODIC PROTECTION ❑ ROTARY Type of Groutfes' %E❑ DISPOSAL ❑ OTHER Other Information L ! J h ❑ GEOPHYSICAL Surface Seal Installed By: w PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done ` PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Z 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 P ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I``will call for a Grout Inspection prior to grouting and a final inspection. "] Signed X �h �_ l/ r lb�yt L�UAIV �1�2 �J1( � 0, . Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLYly�ssl PHASE I W "F Application Accepted By Date 7 ► Additional Comments: Phase II Grout Inspection 1 Phas iin�ection inspection 8y D�te Inspection By to /rL , Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑'EACH ❑ January 1 &Received By January 31 Uu &Received By July 31 e REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. issuance Date Mailed Delivered . �'�- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 /':"