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j� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. IIFOR OFFICE USE: l APPLICATION trjyy�10 1®T66e (For Non-Transferable, Revocable, Suspendable) 4 4 PUMA&WELL ENVIRONMENTAL. HEALTH PERMIT (COMPLETE IN TRIPLICATE) (D (E d 6 x(64 l6-FCT Aa-4WATER QUALITY (p r 5't9 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 is made incompliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Saa � � a reit e le , City/Town it Owner's Name Phone Address s,/ S . T 'Pa -uX 999 City SAl�/ Contractor's Name �/ ate. License# 1�J3 7 � Business Phone — Contractor's Address ✓ Emergency Phone Is[Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes_ No _ TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well I INTENDED USE TYPE OF WELL t ❑ INDUS ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE- ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing $ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information I a ❑ GEOPHYSICAL Surface Seal Inst led By: PUMP INSTALLATiON: Contractor 94-a oqe Type of PumpH.P. "7 `V PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done ' w � J DESTRUCTION OF WELL: Well Diameter Approximate Depth I� Describe Material and Procedure ' I : I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County a 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 i 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." I will call for a Grout Inspec ' In p 'or toyRuting and a final inspection. (/ Signed X + FIon #le: Trt4 Date: w of Reverse Side) if II j FOR DEPARTMENT USE ONLY I PHASE I ,1111► i Application Accepted By Date Additional Comments: Phase 11 Grout Inspection se IH I Inspec#io jInspection By !`V ls,__ Date Inspection By Fee Is Due: 13ANNUALLY ElPER UNIT ElPER SITE ElEACH ElJanuary 1 &Received By January 31 El July 1 &Received By July 31 REMIT i BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE eo J LESS 1' t PRORATION PLUS PENALTY OTHER 4 OTHER Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 . STOCKTON,CA 95201