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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application #s FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) i {{{ PUMP&WELL ENVIRONMENTAL HEALTH PERMIT COMPLETE IN TRIPLICATE WATER QUALITY S ( TRIPLICATE):'J-_ S'. F4 utr ,C��•d - Applicationisherebymadetothe an Joaquin Local Health Districtfora permitto 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. if Exact Site Address 1- 00/56 10D —H0WJt_A-N fl Rg2AA,!D City/Town 4ATH�41)P� G/FO�Pltly� Owner's Name T �- F//7 C p A) Phone a Address F City 4,4 G�D� �' 4 �'o,e Contractor's Name L t� G License# Business Phone Contractor's Address a2 Emergency Phone Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT X OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ L1 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well 1 �Z INTENDED USE TYPE OF WELL f ,� 13 INDUSTRIAL 13 CABLE TOOL Dia, of Wel! Excavation SO 13DOMESTIC/PRIVATE DRILLED Dia. of Well Casing i� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 0 DISPOSAL ❑ OTHER Other Information G.C�FGAL()6-0771�—CIq f 04-L Surface Seal Installed By: PUMP INSTALLATION: Contractor l Type of Pump H.P. ! PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL. Well Diameter Approximate Depth Describe Material and Procedure I hereby 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 became 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 emmppl persons subject to workman's compensation laws of California." � �!��I will call for a Gr ut Inspection prior to grouting and a final inspection. 1� Signed�lil � wC Title: (Draw Plot Plan on Reverse Side) t� FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase if Grout Inspection1 ase til Final Inspection Inspection By Date Inspection By Date .�_ Fee Is Due: 11 ANNUALLY ❑ PER,'JNIT E-1PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED X � DATE DATE, REMITTED C. AMOUNT j FEE '1�! t-. ! <.• li LESS PRORATION - PLUS - I PENALTY ; !�I OTHER OTHER -- h i Received by Date Receipt No- Permit No. - lWancd Date Mailed Deiivered - APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1&01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 . . }