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Applications Will Be Pro ceased When Submitted Properly Completed. Be Sure To Sign The Application. / f f A FOR OFFICE USE: APPLICATION r Non-Transferable, Revocable,Suspgndable) / PUMP&WELL ._.ENVIRONMENTAL HEALTH PERir"tIT (COMPLETE IN TRIPLICATE) � WATER QUALITY' 4c _ ��r Application is hereby made to the San Joaqui n LPcal Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San J/oaquin County Ordinance!No. 1867'dnd the,rules and regulations'of the San Joaquin Local Health District. Exact Site Address- -�—�{-Fes*--t �..a1r City/Town Owner's Name644 fT" Phone Address ' I• - City. Contractor's Name` L4 A License l/ Business Phone Contractor's Address _)P_U_x..( S Emergency.Phone Is Certificate of Workman's Compensation insurance on File th SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 6:, PUMP REPAIR REPLACEMENT❑ - DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line_Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 6 ' STRIAL ❑ CABLE TOOL Die. of Well Excavation, 'DOMESTIC/PRIVATE ❑ DRILLED Dia,of Well Casing ❑ DOMESTIC/PUBLIC O DRIVEN Gauge of Casing ❑ IRRIGATION d GRAVEL PACK Depth of Grout Seal ❑ CATHODIC.PROTECTION ❑t-1 ROTARY Type of Grout Q DISPOSAL - 0 OTHER • Other Information 0 GEOPHYSICAL r Surface Seal Installed By: PUMP INSTALLATION: - Contractor - t- Type Of Pump — H.P. PUMP REPLACEMENT: ❑ State Work Don _ PUMP REPAIR: ,' ❑ State Work Done DESTRUCTION OF WELL: Weill 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:' 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 persons subject to workman's compensation laws of California." I wl�l:al 1 r 1Grou1 Inspe�cti'on prior to grouting and a final inspection. Signed X C/ 1j gL4 r` Title: tTTas�A _ Date: . . . 'f,Im. (Draw Plot,Plan on Reverse Side) '+ FOR.DEPARTMENT USE ONLY PHASE I !t tx1 Application Accepted By Date .2A94/ `n V4,Additional Comments: , Phase II Grout Inspection ase III fi I Insection Inspection By Date Inspection ByDate, Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ' ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE f BASE. E%PLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION tv PLUS PENALTY OTHER .. 1 OTHER C) 9 Received by Date Receipt No. Permit No. W ante D to Mailed. Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9S201