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Applications Will Be Processed When Submitted Properly compielea. meaura I „W„ III—^rr FOR OFFICE USE, APPLICATION _Fy (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 13 r (70 Application is hereby made e Sa aqui Ltoc�Heaith Distr ,)fora permit to construct and/or install thework herein described.This application is ma comp nce with S Joaquin County�rdinaance No. 1862 and the rules and regulations of the San oaquin ocay, ealth D'+strict. � �L City/TownN Exa6t�i�eRddress �] Q�� G�.o E ft. 1 1 u�rito L.U. Phone Owner's N e O C40 6 City Address • �• �Z.." ��S k Contractor's Name 1l.1 LL License # ��- Business Phone Contractor's Address �� -��C w — Emergency Phone _A 1 y x�� is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No —ZTYPE OF WORK (CHECK): NEW WELL DEEPEN C1 AIR DESTRUCTION❑ WELL CHLORINATION 13WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 13PUMP REP AkR❑ REPLACEMENT 13 ' DISTANCE TO NEAREST: Septic Tank 0 Sewer tines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well i INTENDED USE TYPE OF WELLjib ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation # 11 DRILLED Dia. of Well Casing C ��O v Q IXDOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing. ❑ DOMESTIC/PUBLIC ❑ IRRIGATION 13 GRAVEL PACK Depth of Grout Seal 11CATHODIC PROTECTION Rw ROTARY Type of Grout ; ❑ DISPOSAL ❑ OTHER Other Information ,I ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done ,Approximate.Depth DESTRUCTION OF WELL: Well Diiamme4A - tter — ___1P f Describe Material and Procedure w !l1' IJ I hereby ce ity 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. Hsignature certifies the following:1 certify that in the performance of the work for which this permit Home owner or licensed agent's h manner as to become subject to workman's compensation laws of California." is issued, I shall not employ any person in suc Contractor's hiring or sub-contracting signature certifies the following:"L 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." r I call for a Gro s I for to grouting and a final inspection. s� Z�� Title: (�iJ Date: Signed (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I �f:��0� Date Application Accepted By r Additional Comments: a III Final I pection PD s II Grout I pectlon`�� T ' q� Inspection By Date O Inspection By Date l Fee f5 Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recewed By January 31 ❑ July 1 &Received By July 31 11 REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS { PRORATION PLUS PENALTY OTHER t OTHER Date Receipt No. Permit No. Is man Dae Malted De4ivered Received by 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 6>�.