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Applications Will Be.Processed When Submitted Properly Completed. Be Sure To Sign The Application. (/ FQR OFFICE USE: APPLICATION Ir Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLET� IN TRIPLICATE) d.L�•�/Olio- 02,5- WATER QUALITY. - / S Application Is hereby made to the SanJoaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordin�arL a 0. 1862 an(d� the rules ant)/r/pgu atidns �thhee-San Joa um Local Health District. b' Exact Site Address TT151�/1-�7121�Y1 LL,A' - 4ofj l Doxy �� T�'C> ity�/FbwH-' . — U,�, t Q/1�'J Owner's Name /M/1 �05f'%- -7 . . Phone Address PQ�•�D . 7/% City Contractor's Name � License It 2VYBusiness Phone Contractor's Address _y,�Js� Emgrgency Phone Is Certificate of Workman's Compensation In urance on'File With S,ILHD? Yes,•,�_ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL. ABANDONMENT❑ �. OTHER 0 PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1190 $ewer Lines Pit Privy Sewage Disposal Field Z& y Cesspool/Seepage Pit Other T Property Line Private�Domjstic Well Public Domestic Well j- INTENDED USE 'TYPE OF WELL ` /r y❑�i INDUSTRIAL 0 CABLE TOOL" Dia, of Well Excavation )4 DOMESTIC/PRIVATE ❑ DRILLED'. Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION., 0 GRAVEL PACK Depth of Grout Seal ❑ CATHO DIG PROTECTION ROTARY Type of Grout ❑ DISPOSAL: ❑ OTHER! Other Information J �� ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pomp H.P. PUMP REPLACEMENT: ❑ State'Work Done , PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: - Welj Diameter " , Approximate Depth Describe Material and.Procedure. I hereby certify 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. 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:' Contractors hiring or subcontracting 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:' I will a II fora Grout Insspeccttll prior to grouts g and a fin at inspeetjpn. T Signed X ,�c.C�,S.yJ(I�/ /rte' • Title: Date: It- G/ (Dra Ploi Plari on Reverse Side) -� FOR DEPAA�MENT USE ONLY. " PHASE I Application Accepted By � Date UU Additional Comments: P se I ln routlnspection / y,,... Phase III Final Inspection Inspection ByL/uil •_ Date 10 Inspection`By—L/W-L- .A Date Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PEA SITE ❑ EACH ❑ January 1 &Received By January 91 ❑ July 1 &Received By July 71 BILLING REMITTANCE S REMIT BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED d AMOUNT FEE LESS PRORATION - PLUS t PENALTY `r OTHER t OTHER 5 — Received by I Dae Receipt No. Permit No. Is ante D to Mailed Delivered APPLICANT. RETURN ALL CO IES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201