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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.~ " FOR oFFicE usE: / APPLICATION i (For Non-Transferable,-Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY l ue c �5 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. Exact Site Address } aG _ City/Town G d#1134 0 Owner's Name Address { L Phone j City Contractor's Name EL 0✓I C h �;(� i Nicense#_?� Business Piione,_. 3i�F" 7 Contractor's AddressEmergency Phone t is Certificate of Workman's Compensation Insurance on Fil ith J*"M Yes No TYPE OF WORK (CHECK):. NEW WELL DEEPEN ❑ RECONDITION 13DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑` ` PUIVIP'INSTALLA.T10N ❑ REPLACEMENT❑" PUMP REPAIR❑ _Z DISTANCE TO NEAREST: Septic Tank Ali`414-- Sewer Lines z1e__ Pit P�riv� --� I Sewage Disposal Field400�iCesspool/Seepage Pit /L/r.`Other O �b�Property Line rvate,Domestic Wel O N�PublicDomestic Well - x ---- rte, F� INTENDED USE TYPE OF WELL '- ❑ INDUSTRIAL ABLE TOOL S 4' Dia, of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED �� *, Dia. of Well Casing ❑ DOMESTIC/PUBLIC 11 DRIVEN -: Gauge of Casing c:2 -t, O� ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout seal > TE- ❑ CATHODIC PROTECTION ❑ ROTARY ❑ DISPOSALType of Grout_ �f» e—�^ t ❑ OTHER "' Other Information ` ❑ GEOPHYSICAL �<a Surface Seal Installed By: PPINSTALLATION:# R Contractor 1 r,f}-- �� 6 Sob Type of PumP- H.P.-- - -�- - PPMP`REPLACEMENT: �-6 ❑ State Work Done a- PUMP REPAIR: ❑ State Work Done <: a DESTRUCTION OF WELL: Well Diameter Z� Approximate Depth 1 Describe Material and Procedure i I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `® r 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 x. p y persons subject to workman's compensation laws of California." b I I call for a Grout Inspe 'on prior to grouting and a final inspection. Signed X Title: (, �.-�S � Date: (Draw Plot Pfan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: I � Ph 1 Grotil Ins tion Phase III Final Inspection ' Inspection By�/v to �� Inspection By Date w ' Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By,,july 31 ` SASE EXPLANATION BILLING REMITTANCE $ REMIT, 'I L DATE DATE REMITTED AMOUNT DUE CHECKED FEE AMOUNT .I x IICC . LESS y 'r PRORATION 1 y. PLUS e PENALTY OTHER OTHER Received by ate '' Receipt'No. Permit No. I uance Date Mailed _ t Y Delivered ' APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ _ 1601 E.HAZELTON AVE.,P.O-Box 2009 - STOCKTON,CA 95201. - '}