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U dcaons Will Be Proces��c�t4lhenSubmitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE {'np7 LU� APPLICATION 0 4q-130 --q 7 JAN 19 1982 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL 111 JOAQUIN LOCAIENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLIi IM&TH DISTRICT WATER QUALITY ft"770.15' N.': 6;,, t r v� Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance witi San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addresses /< z7' 2 Al. City/Town # Owner's Name Q w Phone 111! Address City Contractor's Name �AyJ License# Business Phone _ 4 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 11 DEEPEN ❑ RECONDITIONX, DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAiRW REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /no Sewer Lines 10Q __ Pit Privy Sewage Disposal"Field Cesspool/Seepage Pit Other k Property Lyne!Z-5_,Pr`ivate,Domestic Well Public Domestic Well INTENDED USE i t �t TYPE QFWELL�` ZQ a 1 ❑ INDUSTRIAL "t y -CABLE`TLOOL t- # tDia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED 1 K -Dia:.6f,Well Casing I&DOMESTIC/PUBLIC +,[] DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information a ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type.-Of Pump .� H.P. SSC PUMP REPLACEMENT: State Work Done -- xm PUMP 1EP;41Rj ©- State Work Done gyp= � ��rn „ e' y - -111 DESTRUCTION OF WELLi �3tilel( Diameter �lApproximate Depth 1 at 'Describe Material and Procedure 1 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:"I certify that in the performanceof 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." ill call for a Grout In ction prior to routing and.a final inspection. Signed X a �-�ir Title: rrW,rC� t`"" n1 Date: 1 ,N� !I (Draw Plot Plan on Reverse Side) L•. t FOR DEPARTMENT USE ONLY r PHASE Application Accepted By ' � � re'�a — Date Additional Comments: Phase 11 Grout Inspection Phase Fi I Inspection Inspection By. D t Ins n Date Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DJE CHECKED DATE DATE REMITTED AMOUNT FEE > LESS PRORATION PLUS PENALTY OTHER l }I - OTHER � Received by Date Receipt No, Permit No Issuance Nate Mailed Delivered .1 APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201