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Applications)Will Be Processed When SubmittedProperly k FOR OFFICE USE: APPLICATION (For Non-Transterable, Revocable, Suspendable) pUMP&WELL ENVIRONMENTAL HEALTH PERMIT I WATER QUALITY (COMPLETE IN TRIPLICATE) Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand!orinstalltheworkhereindescribed.Thisapplicationis made in compliance with Sl. anJo �III�In Cou y Ordin a No. 1862 and the.(ru s and regulations of the San Joaquin Lo.cal Health District. r CitylTown ! Exact Site Address II Phone ' Owner's Name 7jl City qJ Address Q yp� R L5 icens�[V. Business Phone Contractor's Name Emergency Phone l W Contractor's Address _ l( Is Certificate of Workman's Complensation Insurance on File With SJLHD,I Yes STRUCTION❑ TYPE OF NDE WORK (CHECK): NEW WELLDEEPEN❑ RECONDISI,ON li ,1 j-- R-0 .P.UNIr NSTAL`LATION��UMP REPAIR❑ WELL CHLORINATION 13WELL_ ABANDONMENT ❑ REPLAtG {V1ENTr ) #' I E'' `Q_ � Sewer Lines F Pit Privy DISTANCE TO NEAREST. Septic Tank ,_ y h Other G Sewage Disposal Fid ®/t/ Cesspool/Seepage Pit S Property linea Private Domestic Well Public Domestic Well ' INTENDED USE TYPE OF WELL ! / _ I ❑ CABLE TOOL of Well Excavation- 11INDUSTRIAL I ; _ $ ❑ DRILLED Dia: of Well Casing O ESTIC!PRIVATEu.- ❑ DRIVEN Gauge of Casing '' f ❑ DOMESTIC/PUBLIC �fl, $ 1 ❑ IRRIGATION ❑ GRAVEL PACK !f Depth of Grout Seal I!, i i �6TARY Type of Grout ; I 0 CATHODIC PROTECTION r "1 ❑ OTHER 1, Other Information k ❑ 4111111, DISPOSAL l 4(' Surface Seal Installed B' E 13 GEOPHYSICAL t Contractor # PUMP INSTALLATION: l l p ' Type of Pump ❑ State Work Done PUMP REPLACEMENT: ❑ State Work Done h`- PUMP REPAIR: rs Approximate Depth DESTRUCTION OF WELL: Well Diameter I ' ' Describe Material and Procedure re ared,this application and that the work will be done_inlaccordance with San Joaquin County k I hereby certify thatil ha.1. _ .p ! ordinances, state laws, and rules and regulations of the San.�Joaquin Local Health District. i Home owner or licensled agent's signature certifies the following:1 certify that in the performance of the work for which this permit is issued, I shall notllemploy any person in such as to become subject to workman's compensation laws of California." # Contractor's hiring ollf 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." h � l will ca I for G � inspection prior to groutin nd a linall inspection. ur Date: i Title: ! X Signed 6 f•.�j (Draw Plot Plan"on Reverse Side) FOR EPART NT USE ONLY PHASE 1 a 'I h ej Date , J-7 - P' Application Accepted�tsy. r*'� Additional Comments: Ip qp JI �phas NI Final Inspection y j Ph e Ir Grout inspection d / 2 y ,I R '• Bate t�Inspection By Dat ; .y j Inspection By �, I� � � Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Receiv REMIT 31 .1: BILLING! REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE )` DATE °- REMITTED AMOUNT 0 FEE R� 4 LESSI I. PRORATION ;ll� IiIi PLUS JI, I PENALTY 111 i OTHER e i HII — i0 lssuanc Date Mailed Delivered i Received by �I Date Receipt No. ��Permit o. �-w 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,'CA 95201 e APPLICANT—RETURN ALT COPIES TO: ENVIRONMENTAL HEALTH-PERMITISEHVkCES •+�'- IF .� .