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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _FORG FIC sh )n tyourJl�u APPLICATION 1 b (For Non-Transferable,Revocable,Suspendable) ( PUMP&WELL /7 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install thework herein described.This application is made in compliance with San Joaquin Cciunty, dinancp No. 1862 and the rules and regulations of the San Local HHeera,Ith District. Exact Site Address City/Town K"_L O/i,� Owner's Name—'G `�4—/ Q� 0 Phone—. J Address ___-_____- — _. City Contractor's Nam _ Business Phone--,?,I3 CW ' Contractor's Address �� JV�f'--Emergency Phone IR!t/7^.6 _oa Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4--- No _ TYPE OF WORK (CHECK): NEW WELL@�_'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank sU-___1L__ Sewer Lines��y� Pit Privy Sewage Disposal Field— � Cesspool/Seepage Pit At�a Other _ Property Line '^" Private Domestic Well B�Iblic Well INTENDED USE TYPE OF WELL �RRf 4�'{! SV 0 ❑ IN�DI"1STRIAL ❑ CABLE TOOL Dia. of Well Excavation // " - 0'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 rzp -0 DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing _-_...__. l ❑ IRRIGATION -- 1:1GRAVELI PACK Depth of Grout Sea d ❑ CATHODIC PROTECTION CRY / Type of Grout _. ❑ DISPOSAL ❑ OTHER Other Information_.-. ❑ GEOPHYSICAL ' Surface Seal ailed By:n u Six /At C► Contractor PUMP INSTALLATION: Type of Pump _.. H-P._ PUMP REPLACEMENT: ❑ State Work DoneT — —� PUMP REPAIR: ❑ State Work Done ---- DESTRUCTION OF WELL: Well-Diameter Approximate Depth �t 1 Describe Material an1d Procedure __ V 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 is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.' Contraclor's hiring or sub-contractin signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ sons bject to workman's compensation laws of California. I I call for a Grout 1 s r to gr tin and a final Inspection. 2 3 S�- , „ Signed X � Title:l o �Y'� (w1Ci_�t_ � Date: raw Plot Plan on Reverse Side)I. l CC FOR DEPARTMENT USE ONLY P 1 _ 1 AppliCalion Accepted By Date Additional Comments- Phase omments Phase 11 Grout Inspection (D 'I S" fCvv Phase III Final Inspection � Inspection By .._.___ Date_—/ v r.��urInspection By___ Date — r► Fee Is Due: ❑ ANNUA''_LY j]PER UNIT • ❑ PER SITE ❑ EACH ❑ January 16 Received By January 3' ❑ July I &Hecerved By JL-ly 31 BILLING REMITTANCE S REMIT BASE EXPLANAIION GATE DATF REMITTED AMOUNT DUE CHECKED AMOUNT FEE 41 ql PRORATION Zc/ ( ��yy~1 / t.zL- `. 7-77 PLUS ! //_ � PENALTY OTHER OTHFR Received Fy I, Date Receipt No. Permit No. Issuance Date Mailed Oclrvered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo.2009 S_TOCKTON,CA 95201 `