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Applications Will Be Processed When Submitted Property Completed,Be Sure To Sign The Application. J FOR OFFICE USE: APPLICATION 101 Non-Transferable, Revocable,Suspendable) PUMP&WELL 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 Or No.Ngo.--1�j d the rules and regulations of the San Joaquin Local Health District. Exact Site Address—��Ji1/T )�' //,c/ ice—' Citylrown % L1 Owner's Name PCo)r •, ;• Phone Address I e. / City 1 Contractor's Name C'.Q/n/A'TFp a4&4'/�t�LXdicense# '. ? . Business Ph e� Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurai on File With S11LHD? Yes' _ No U TYPE OF WORK (CHECK): • NEW WEli t DEEPEN ❑:' RECONDITION[] ' DESTRUCTION❑ WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank "//P!L E;E! Sewer Lines�_ Pit Privy Sewage Disposal Field_;/1_�� Cesspool/Seepage Pit Other Property Line . . _ Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 11 INDUSTRIAL 1:1 CABLE TOOL: '•t Dia. of Well Excavation /2 s -NZDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing PLIG ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ;0 Pl ❑ CATHODIC PROTECTION �'9OTARY Type of Grout �j,FA11�, ❑ DISPOSALIb] OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor ' Type of Pump H.P, PUMP REPLACEMENT: state Work Done ` PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: - Well Diameter Approximate Depth -4 Describe'Material and Procedure I heteby certify that I have prepared this application and that)he work will be done in accordance with San Joaquin County ordinances,state laws, and rules'Aj d 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will ca, too a Grout Inspection prior to grouting and'+final Inspection. Signed X Title: Date: (Draw Plot plan on Reverse Side) FOWDEpARTMENT USE ONLY=' 1, PHASE I `•j /// /y j Application Accepted By _ " `/ Date ' Additional Comments: Phe B II Grut Inspection Phase II incl Inspection InspectionBy� �� Date��' ' Inspection By Date Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE• . '❑ EACH ❑ January 1 a Received By January 31 ' ❑ July 1 8 Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION AMOUNT OUE CHECKED DATE/ DATE REMITTED AMOUNT FEE � 3 < 4 3-- LESS / •i 44 PRORATION ' PLUS PENALTY OTHER Dt OTHER IL Recened by Dale Receipt No. Permit No. lmu&dc6 D30 Mailed . Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 2 STOCKTON,OA III