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• Applications Will Be Processed When Submitted Properly Completed. BeSureTosign ineAppllcauon. _ [FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL -y ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. r Exact Site Address so �WF_ D City/Towne Tt Owner's Name It: I- ! 1tE Phone ��5• � _Ii u�+>�- � � City Address � 510 Business WL" S Contractor's Name �. L�+ _p License# Contractor's Address � _ Emergency Phone *16 f Is Certificate of Workman's Compensation I,nnsur �n File With SJLHD? Yes f� No i TYPE OF WORK (CHECK): NEW WELL L? DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Clz WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMEf T❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Q1b t — Pit Privy 5ewa e_D.is osaLEa.eld.- 1;y -=,Cesspool'/_seepage-P_it Other «– � -- 9 P � - . Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL id +. ❑�,�I USTRIAL 11 CABLE TOOL Dia. of Well Excavation-- 1 64r_ 16! 0? OMESTIC/PRIVATE _❑ DRILLED Dia. of Well Casing [ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I ❑ IRRIGATION 45 y' $❑ C�IrYEL PACK Depth of Grout Seal Park,�10-rG U, F 11 CATHODIC PROTECTION . ROTARY Type of Grout ❑ DISPOSA12 '4© OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: iii PUMP INSTALLATION: Contractor k t 3 Type of Pump _ n# H.P. a Y PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 4 DESTRUCTION OF WEL1 _. a,w > Well^Diameter` ` Approximate Depth .Describe Materia a Prcceo r F � s so Thereby certify that_Ihave prepared dhis;.a5.piieation and that the work will be don in accordance with San Joaquin County ��ordinances, state IawSjand rales and-regul"dtlons`-of the San Joaquin.Local Health District. r .. A :Home owner or Ifcensed agent's signature certlhe�the following �leltify 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 'u ject to workman's compensation laws of California." I' RCo' tractor's hiring or sub contracting signature certifies�he following:"I certify that in the performance of the work for which this Pe it is issued, I Pall employ persons subject to workriiag'&compensation laws of California." 1'wl all for a Gr utspe on r�tgro�ufingnd 2f fina1 inspec�tio�n�'�' ```` +� C Signed X �., - Title: � .-1n� P� �E+�.Date: G�• i I (Draw Plot Plan on Reverse Side) j FOR DEPARTMENT USE ONLY f p ^11 Ck S PHASEsI j y �..- C) s Date o�11 CA Application Accepted By. I Additional Comments: ' } Phase 11 Grout Inspection h II F' I Inspect! �� 4 Date �� Inspectiori By Date Inspection B f !rte^ Fee Is bue: ❑ ANNUALL(a _❑.PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 & e eived By January 31 ❑ July 1 &ReceivedREMITuiy 31 i -� � ..`e`�•'+ ' BILLING¢ REMITTANCE $ s -'x*` �'ABASE EXPLANATION 'AMOUNT DUE CHECKED REMITTED .,-. ,.7. DATE DATE AMOUNT fes. w � r FEE425 PRORATION ®V � S y- .r� ��✓ • PLUS PENALTY - OTHER - ?C( Nem cr - i afJ�j %h rJle OTHER " Received, y Date -.- Receipt No:y Permit No.,, l6suanbd Iff5afe Mailed DeSivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER MITtsEAYlCFS, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201