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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL y t ENVIRONMENTAL HEALTH PERMIT t i . WATER QUALITY (COMPLETE IN TRIPLICATE) Application is hereby made toth?eSan Joaquin Local Health District-fora permit to construct and/or install the Work herein described.This application is compliance with San Joauin County Ordinance Nb 1862 and the, rules and regulations of the San Joa�guin Local+He made in alth District. SanV05'MI.hch;. .' City/Town "'i°'frac Ca %' Exact Site Addtess 9r 1 - _ 815-2922 Owner's Name tr " r DOI1 OS -I D O ,Mo-,C ns �- ttOri Phone• ra cy , Address — ,. ' x3S] 3:1e City,, 5 Hennin S <BrOS,Dril.l.ing . ' ' License# .2 081 . Business Phone, -� 18 �r Contractor-s`Nalne LF _1.1 $ Contractor's Address 2 Pel'azd&fie `AVe> � ';'Emergency.Phone,, Is Certificate ot'Workman's Compensation insurance on File With SJLHD? Yes X No i TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONbITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL.ABANDONMENT 13 .. OTHER C1 .'I PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT[] .. . Pit Priv DISTANCE TO NEAREST: Septic Tank' 00 Sewer Lines . Y .� Sewage Disposal Field 1 00. -• � .,Cesspool/Seepage Pit Other. Property Line Private Domestic Well Public Domestic Well ',. .y,,,,�_...�: ,• -.--.TYPE OF WELL.. ..., a-�,.,,. .:.,.�.,�,..:e-.....,�- t.o...- ,.•�--�, 1 INTENDED USE _ pia. of Well Excavation ❑. INDUSTRIAL r 0 CABLE TOOL tt I 13 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Dvc 16o ❑ DOMESTIC/PUBLIC -g-DRIVEN Gauge of Casing 11IRRIGATION . GRAVEL PACK. Depth of Grout Seal • 'iii 11 ROTARY Type of Grout nt ❑ CATHODIC PROTECTION ❑ DISPOSAL w '� ❑ OTHER Other Information 11 GEOPHYSICAL k , . Surface Seal lnstalled-By: Driller PUMP IContractor INSTALLATION: F t TYpe.of Pump - H.P. PUMP REPLACEMENT: - -❑ State Work Done PUMP REPAIR: ❑ State Work Done v I DESTRUCTION OF WELL: f Well Diameter `t ApproximateDepth I Describe:Material and Procedure I hereby certify that Chave prepared this application and that the work will be done!in accordance with San Joaquin County r' ordinances, state-laws, and rules and regulations of the San Joaquin Local Health District. 4 i Home owner or licensed agent's signature certitiesahe foklowing:"I certify that in the performance ofthe 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." € i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in�the perfarman�ce of the work for which this permit is issued, ! shall employ persons'subject to workman's compensation laws of California f F ;f ill call•lor a Grout Inspection prior to4gfoutin.gpnd a final inspection. - I1 '>, Title; � Pr e s id ent , - Date. Jul 12s 1983 - Signed X ' (Dw Plot Plan on Reverse Side) t FOR DEPARTMENT USE ONLY PHASE II 7 s! " Date f 11 Application Accepted.By Additional Comments yJ Ph se� rout Inspectio ' Phase lll'Final Inspection Inspection By,�'N + Date POT Inspection By •'� Date Fee Is Due:11 ANNUALLY. -0.PER UNIT' El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Receiv REMITBy uly 31 t BILLING_ REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE } DAT£ REMITTED AMOUNT x _ .. - FEE LESS. PRORATION - PLUS J ' PENALTY- OTHER OTHER D e _ Receipt No, Permit No. Issuance Date .Mailed Delivered - Received by- '' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 StOCKTON,CA 95201