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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FORQFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ---- -- ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lpcal Health District. Exact Site Address i-I 3!7 l rZ�''t?C/-f C — City/Town A-7 Owner's Name Address _ Phone L�- � 2� �s _— Contractor's Name •>! APR( w ' j �7, P_" `�" s�i+z� /1/�LicenSe# Business Phone Contractor's Address /!� d � fLl�mergency Phone Is Certificate of Workman's Compensation Insurance T, File With SJLHD? Yes_ �� No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ OESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION W- PUMP REPAIR Q� REPLACEMENT❑ l DISTANCE TO NEAREST Septic Tank Sewer Lines Pit Privy Sewage Disposal Field 7 Cesspool/Seepage Pit Other Property Line_�- Private Domestic Well_._ Pubiic Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia of Well Excavation— 05-_60MESTIC/PRIVATE ❑ DRILLED Dia of Well Casing El _.__.......---- DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor�U Type of Pump cJ fj _- H.P / PUMP REPLACEMENT: ❑ State Work Done —+-� _ PUMP REPAIR: ❑ Stale Work Done — DESTRUCTION OF WELL: Well Diameter_-_— _ Approximate Depth . 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 Home owner 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 taws of California." J I will call for a Grout Insp ctlon prior to gr uting and a final Inspectio Signed X Title: Date; � i1�_ l (Draw Plot Plan on Reverse Side) / FOR DEPARTMENT USE ONLY PHASE I ` Application Accepted By "` �/�—_-....._ Date Additional Comments: X91 Phase II Grout Inspection Phase III Final Inspeclion Inspection lay_ � Date Inspection By k, _ Date ZY/2— 7— Fee Is Due: ❑ ANNUALLY ❑ PER IJNI— ❑ PER SITE ❑ EAC1l0 January 1 &Received By Ja•*uary 31 ❑ July'd Received 6y JuI/31 BASE EXPLANATION BILLING I REA!I-TANCE I S REMIT A DATE DATE REMIITED MOUVTDUE CHECKED J AMOUNT FEE: 5r,- - LESS PRORATION lJW P,-(/v f tl/ &/ '1j"PENALTY U p� OTHER /10 f16 ! - ,S-ew U�� i✓c! Lihi�� rG! 6e L.),,d y OTME Received oyi t No ANQ o. I seance ate ' Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES"ter 1601 E.HAZELTON AVE.,P.O.Bea 2009 STOCKTON,CA 95201