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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. /- FOR OFFICE USE: APPLICATION !/ (For Non-Transferable, Revocable;Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY „�1 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 Joaquuiin County Ordinance No. 1662 and the rules and regulations of the San.Joaquin Local Health District. ' Exact Site Address 3Q� City/Town Z. Owner's Name "�� .�E,>�,�J��.E ^.'3: Phone +FS-- Address 0 -SeuTA IW!.W AT 14L4-A: _ city Contractor's Name LL >(L k}t41; �u11 L4i1"4E7~1"T tp, nse# ?L Ll Business Phone:, Yb L- sio QN- Contractor's Address c1*014 `�� '`'y ' Emergency Phone r` Nhw- +. Is Certificate of Workman's Compensation Insqpace onFile With S_JLHD? Yes No TYPE OF WORK (CHI=CK): NEW WELL DEEP_EN ❑ '-_PRECONDITION❑' - DESTRUCTION❑ - WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT❑ _ { F ZOO i t DISTANCE TO NEAREST: Septic Tank 7-DD Sewer Lines Pit Privy I Sewage Disposal Field Cesspool/Seepage Pit Other Property Line_ Private Domestic Well Public Domestic Well INTENDED USE .�T PE OF WELL 4 g L3 INDUSTRIAL L`�CABLETOOL Dia. of Well Excavation 10 ❑ DOMESTIC/PRIVATE ❑jDRILLED Dia. of Well Casing ❑ Q MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing •1 E G� IRRIGATION __..__,.,......,..-❑ GRAV.EL_RACK . -Depth.bf-Gro ut.Seal_ ' ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout i ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor l r Type of Pump. H.P. ' N PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter I Approximate Depth 4" bn E ,, ( .- Describe Materia' and,Procedu e 'Al i r ,)),hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County o?dsnances, state laws, and rules and regulations of the San Joaquin Local Health District. HoMik owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i is issued, I shall not employ any person in such manner as to become subject', workman's compensation laws of Califoroia." Contractor's hiring or sub-contracting signature certifies the following:"I certify.that in the performance of the work for whiGh•ts �. permit is issued, I shall employ persons subject to workman's compensation laws of California." l.. I ca a G Inspe„ ion pno to gr ting and a final inspection. Signed Title:.��(Is.�> Date= 2" I""V ` (D w Plot Plan on Reverse Side) 1:y t FOR DEPARTMENTJt3SE ONLY .j PHASE I ;t , p • Or Application Accepted By ' �.�"�'. .�?d:.' $ .... Date I� D Additional Comments: G • � ;""� „•„ � -,.t•. a ,,-.;*�.a '�•,,, r • _ {.;� i Phase II Groul,lnspection - - j �k� s;',,�zg jfp , ha ill Final pection Inspection By Date Inspection B a-!!`%G all t ate Fee IS Due: 11 ANNUALLY ❑ PER UNIT ��,-❑ PER'SITE 11 EACH ❑ January 1 &Received By Janilary - ❑_July 1 Received By July 31 REMI BILLING REMITTANCE $ 611 T BASE EXPLANATION DATE DATE ;ffiEMIT7ED AMOUNT DUE== HECKED '\ r, AMOUNT FEE LESS PRORATION PLUS 'i M PENALTY OTHER12 6 i Received by - Date Receipt No-' --�-. Permit No. - - ssuance ate .Mailed Delivered# `�' APPLICANT-r-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520i