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Applications Will Be Frac_essed WIIen Submitted Properly Completed. Be Sure To Sign The App@Ication. FOR OFFICE USE:_ '' APPLICATION 1 1 (For Non -Transferable, Revocable, Suspendable) ` PUMP & WELL 1 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is`hereby made to the San Joaquin Local Health District fora permit to construct andior install the work herein described. This application is made in compliance with San Joaquin Count} Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address ��/Q�� /(/%`.Q 9 CityJTown Z / Owner's Name _ XZ Vt— ls-oL� Phone/�_ Cy, Address �,J dam__.. / 00 City—C�..rT�d Contractor's Name __l�a,o License S7 Business Phone__ t_.. Contractor's Addres_ sa q� /(� `—�./�o Cys�l=mergancy Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No TYPE OF WORK (CHECK): NEW WELL &DEEPEN ❑ RECONDITION ❑ DESTRUCTION ❑ �(� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®PUMP REPAIR ❑ X17 REPLACEMENT ❑ r DISTANCE TO NEAREST. Septic Tank -+ Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit _ Other Property Line—y4_1 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑CABLE TOOL Dia. of Well Excavation—,—.... 9�"i?Q STIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ I ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing / ❑ IRRIGATION I' ❑ GRAVEL PACK Depth of Grout Seal s`G+ ❑ CATHODIC PROTECTION .17�IIQTARY Type of Grout � ❑ DISPOSAL _ ❑OTHER Other Information _ f_ _ ❑ GEOPHYSICALurface Seal Installed B op PUMP INSTALLATION: Contractor a JJ Type of Pump i H.P. PUMP REPLACEMENT: f ❑ State•Work Done- PUMP REPAIR: ❑ State Work Done _- DESTRUCTION OF WELL: �� Well Diameter _ Approximate Depth F _ 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. 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 - Contract or's alifornia-Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this iy permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to groutin and a final inspection.` Signed X _ Title: "ISate 1 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 J i Application Accepted By IL —_._ _ _ __ _____ _— _-. ___ _ _ Datel_''� Additional Comments: r Pha a II Grout In ec n A� Phpse.411 Final inspection Inspection By a2l te�~ (l Inspection B Date Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑PER SITE ❑ EACH ❑ January 1 5 Received ByJanuary 31 J« Ay Received Dy .:uly 31 BASE h I F.xpt ANATION FEE pp I ESS PRORATION BILLING I REMITTANCE I S DATE DATE REMITTED PLUS PENALTY OTHER OTHFR C ___$.. � � � F's i-3 L1 AMOUNT DOEJ CHECKED AMOUNT Received byate . Receipt No Permit No. . _ Issuance Date Mailed Delivored - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E HAZELTON AVE.. P.O. Bos 2009 STOCKTON. CA 95201 _