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1 A a1 s IleVroces y _ ubmiiked Proper) Coiripleted.`Be Sure To Sign The Application. FOR OFFICE USE: SSP r g 198 APPLICATION j L. or Non-Transferable, Revocable, Suspendable) PUMP&WELL E�X[RONMENTAL HEALTH PERMIT i SAS;! J40AQUI-N LUWATER QUALITY (COMPLETE IN TRIPLICATEfJEALTH DISTRICT 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 H alth District. Exact Site Address 1C�C V City/Town Owner's Name �gse,24, � Phone - JAL- Address JI11Address f C K 0102 V City . Contractor's Name dTfSe# 311 T 1-Business Phone 3.7 30 Contractor's Address Emergency Phone _ 34 9 S Z I Is Certificate of Workman's Compensation Insurance-on File With'SJLHD? Yes No(tK:) Nd A A4104'0L74' —r TYPE OF WORK (CHECK): NEW WELLPC — -DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPUACEMENT;❑ .-It✓ sroLI> WaLZ7 IZ04' L-0IEA-(Srv.-CIe.s DISTANCE TO NEAREST: Septic Tank /JD Sewer Lines f Pit Privy T' Sewage Disposal Field_ ( Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well 1� INTENDED USE TYPE OF WELL ��i� � 13 INDUSTRIAL' CABLE TOOL Dia. of Well Excavation t7 ti/O V- ,9DOMESTIC/"PRIVATE ❑ DRILLED Dia. of Well Casing � ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casinga ' ❑ IRRIGATION 11GRAVEL PACK Depth of Grout Seal b ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout NQS - ir� ❑ DISPOSAL # ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: iI H.P- PUMP REPLACEMENT: n] ne PUMP REPAIR:{� J V ❑ State or DESTRUCTION,OF WELL ! Well P th " Describe Material and Procedure I her 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work:forwhich.this permit is issued, I shall employ persons subject to workman's compensation laws of California." I'will c I f r'a Grout•Insp tion o grouting and a final inspection. I Signed X II Title: �/�� Dpi — Date: { raw Plot Plan on Reverse Side) + I' FOR DEPARTMENT USE ONLY i Q PHASE I� n �Q,4� Application Accepted By `r L Dat Additional Comments: Phase 11 Grout Inspection ` Phase Ili Final I ectkon Inspl�ction By�r Date 911 14 Inspection By Datef 1! i - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.lianua,y 31 ❑ July 1 &Received By Juiy 31 II BELLING REMITTANCE $ REMIT I AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED ,I, AMOUNT 1 -143 FEE I "" LESS PRORATION PLUS PENALTY j 6 OTHER OTHER y - - ,y Received by Dae Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 '"