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t is I"Be£P>liceated Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: i l .w APPLICATION (Fo Transferable,Revocable,Suspendable) PUMP&WELL DEC 3 11982 ENVIRONMENTAL HEALTH PERMIT aka / � S . 1- A �liiV r�# WATER QUALITY flt t: �1—i.v (COMPL TE INT IPLICATEr>a - , Application is hereby made to the Sar� �SKaa District fora permit to construct and/or Install the work herein described.This application is made in compliance w1th�S n Joaquin ouunity3Dbr manceNo y1862 a the rules and regulations of the San Joaquin Local Health District.. Exact Site Address._� City/T6wn . -?-7� f 2CQ - r1sa_a n �C� Owner's Name �--�+� ��'� __' ' - Phone_d Address E R60 Cc1._�. •�-3 ............. } City Contractor's Name � '{�-��_ License IvA;�D, 3 2 Business Phone Contractor's Address t Emergency Phone �7 ,S Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes ✓ No TYPE OF WORK (CHECK): - NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -- _ WELL CHLORINATION ❑ WELL„ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR t9' REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field _..._._._ _ Cesspool/Seepage Pit Other.____._ ` Property Line__. _ Private Domestic Well .• .. PGblic Domestic Well -- INTENDED USE -_TYPE OF WELL o - ❑ INDUSTRIAL y❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dial. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing CT IRRIGATION ❑ GRAVEL PACK De th of Grout Seal __ _--_.._.......... r 11 CATHODIC PROTECTION ❑ ROTARY Ty e of Grout _ ❑ DISPOSAL ❑ OTHER _-_ Ot er Information ❑ GEOPHYSICAL ��rfac�e Seal Installed By. _1 PUMP INSTALLATION: Contractor � N Type of Pump H.P. _____.-.. N” PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0/State Work Done DESTRUCTION OF WELL: Well Diameter �� Approximate Depth -� Describe Material and Procedures I hereby certify that I have prepared this application and464e^w rk will be done In accordance with San Joaquin Cou tyj ``�� hr-'V• ordinances, state laws, and rules and regulations of thv� aq 7paquin Local Health District. Homeowner or licensed agent's signature certifies the'follovi lfig:"I ceAify that in the performance of the work for which this permit is issued, I shall not employ any person in such4annes to became subject to workman's compensation laws of California.' p Contractor's hiring or sub-contracting signature ce6tie"s the following "I certify that in the performance of the work for which this permit is issued, I shall employ person§,gubjed-�0'workman's compepsation laws of California." I w call for a Grout 1 ppcti�n-�rl6ir to-6r (Ing and a final Inspection. M Signed X C .:... 111e: w �'2/ Date: ( 6raw Plot Plan on Reversetgfde) FOR DEPARTMENT USE'ONLY PHASE I Application Accepted By rf � ;.._.�_� -__._.__ ,._......____.._ . Date Additional Comments: -- --= — --- Phase II Grout Inspection I f 1 Final Inspection / p� Inspection By- -__ _ Date_._ _J Inspection-By '�' Date Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ £AGH I❑ January i &Receiv y Jar) l ❑ July 1&Received By July 31 REMIT BASE ExPLANATION eBILLING --REMITTANCE 3 AMOUNT DUE CHECKED ��f�•` DAT BATE. Fl I 'yFD� AMOUNT FEE LESS PRORATION ....._......_._. I -- — PLt1S i ^i PENALTY OTHER F OTHFR Received by Date Reci No. Permit No. - - issuance Date Malled4 Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-eo:2909 STOCKTON,CA 95201