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.%., Appucationswill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. o 'ICE USE: � � APPLICATION (For Non-Transferable, Revocable, Suspendable) t ENVIRONMENTAL HEALTH PERMIT PUMP&WELL 0 (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made tothe 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 Local Health District. Exact Site Address T Kite east Hewitt toad & 'T I':.1 e I,orth Hwy City/Town T Owner's Name Joseph Spnig linetti Phone Address 18626 2. Co Jero of a City T 'r idpr Contractor's NameY`UrVi3lace Drillers Dri11 in u0T1Prense# 377923 Business Phone 3?=44 68 Contractor's Address r.0.110X 64 1T infer,Vn' i f 95236 _ Emergency Phone 6N Is Certificate of Workman's Compensation Insurance on File With SJLHD? �'Yes X ].r, mai'?) No TYPE OF WORK (CHECK): NEW WELL ER DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1. 0-3 1 a Sewer Lines 1 tn7'i e Pit Privy Q Sewage Disposal Field 1 MD e Cesspool/Seepage Pit Other Property Line Private Domestic Well '1�e Public Domestic Well � INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ® CABLE TOOL Dia. of Wel! Excavation 1211 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1211 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 188 iiia'!1 ® IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL © OTHER Other Information ❑ GEOPHYSICAL Surface Sea! Installed By: PUMP INSTALLATION- C661ractor ., Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done_ PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth CJ Describe Material aiJA Procedure I hereby certify that I have prepared this applica11i°°�� and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations o lhe San Joaquin Local Health District. Home owner or licensed agent's signature certifies thI€l€efoflawing:"I.Certifythat in the performance of thework 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 for whichthis permit is issued, I shall employ persons subject to workman's compensation laws of California." I will tali for a Grp spection prior to grouting and a final inspection. Signed X Title: President Date: 914 3/79 (Draw Plot Plan on Reverse Side) FOR DEPART NT USE ONLY PHASE I Application Accepted By j Date O' Additional Comments: Phase II Grout Inspection III al Inspection Inspection By Date Inspection By Date -' 1Z� Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 �❑ July11 &Received By July 31 BILLING REMITTANCE $ ° REMIT BASE EXPLANATION AMOUNTDUEI CHECKED DATE DATE REMITTED AMOUNT i FEE LESS PRORATION .. PLUS PENALTY - OTHER OTHER Received by - Date Receipt No. Permit No. I suance Date Mailed Delivered } APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201