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Compiezeu. �^ Applications Will Be Processed When Submitted KATION _ PUMP&WELL _FOR OFFtC£ SSE: (For Non-Transferable,Revocable,Suspendabse) --°'-- ENVIRONMENTAL HEALTH PERMIT - ----- WATER QUALITY application is (COMPLETE IN TRIPLICATE)he San Joaquin Local Health District for a permit to construct and/or install the work herein described.This Application is hereby made tot Ordinance No. 1862 and the rules and regulations of the San"Joai I Health District. t�-�' (lance with San Joaquin County —�City/Town —�cIj- made in comp ! � �! --I � I Exact Site Address Phone� =3 jgw . SAlA f es- --- City ��7 —SP Owner's Name , VE`,_. —— Business Phone —1 Address — j) �L>t/�;—; License# L - C' L��-✓j-L�� ____ Emergency Phone �-- --�— Contractor's Name --� __ No --- �� Yes - Contractor's Address �—��— , DESTRUCTION❑ is Certificate of Workman's Compensation insurancDeFjPEN C3Ith, RECONDITION ❑ PUMP REPAIR TYPE OF WORK (CHECK}' NEW WELL R. ❑ OTHER ❑ PUMP INSTALLATION \ WELL CHLORINATION❑ WELL ABANDONMENT — _ Pit Privy �— —.— REPLACEMENT❑ tic Tank ��1 Sewer Lines---—— Other Cesspool/Seepage Pit — DISTANCE TO NEAREST: Sep — Sewage Disposal Field — _r public Domestic Well. Property Line_—-- Private Domestic Well — — TYPE OF WELL INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation ❑ IN [I DRILLED Dia. of Well Casing INDUSTRIAL ��,h�-�/� �S•� _ _ DUSTIC/PRIVATE Gauge of Casing ❑ DRIVEN 11DOMESTIC/PUBLiC GRAVEL PACK Depth of Grout Seal . ----—�_ ROTARY aut _ ---- ® Y ❑ CATHODIC PROTECTION Other Information _-- ---�_ ❑ OTHER —— ❑ DISPOSAL Surface Seal Installed By: _ ---—EJ GEOPHYSICAL GEOPHYSICAL Contractor —� H.P.—,——— — PUMP INSTALLATION: Type of Pump_._�--—— — _-- --- — J ❑ Slate Work Done--- PUMP one PUMP REPLACEMENT: —_ Approximate pep V� ❑ Stale Work Done — — Depth —— ——— PUMP REPAIR: Well Diameter ——— --— DESTRUCTION OF WELL: --- — Describe Material and Procedure.-- ---- -- ance with San Joaquin County this application and that the work will be done in accord ... I hereby certify that 1 have prepared I certifythat in the performance of the work onfor laws which California." ordinances, state laws,and rules and regulertifies the ations of the San Joaquin Local HealthDistrict. Home owner or licensed agent's signatureesuch manners as Ito become subject to workman's comp is issued, I shall not employ any powing: I certify that in the performance of the work forwhichthis Contractor's hiring or sub-contracs subject oniature rtitle_ n'sthe sscompensation laws of California." permit is issued, I shall employ person routin and s anal inspection. I will call for a G out Ina tion prior tog 9 Date: —314X�g�—— _ Title: �— Signed X {Draw Plot f Ian on Reverse Side) FOR DEPARTMENT USE ONLY Date,-- PHASE l Application Accepted By -- — — — — Phese 1 I Final Inspection Additional Comments:—,. —inspection inspection s Date -- — — ESe I routlnspec f�� Inspection By_ � Date.�-�---� _ Inspection By-72T — ]uIj I &Received By July 31_ ❑ EACH ❑ January 1&Re `-a BY 3anua`Y 31 ❑ REMIT PER UNIT PER SITE � AMOUNT DUE CHECKED Fee is Due: ❑ ANNUALLY — — -BILLING REMITTANCE REMITTED AMOUNT — BASE EXPLANATION DATE DATE !� FEE — --- LESS 1— PRORATION _ PLUS PENALTY OTHER — OTHER Mall;; Delivered it No. Issua Date CA 85205 STOCKTON, - Received hY Date RecelAt NO 1fi05 E.NAZELTON AVE,P.O.eo<2009 _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEAL7N PERlAITlSERYICES