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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For 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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address TJ City/Town _��d 42:2 Owner's Name Ca Phone ss-,- - Address O v 6? City 40 r, Contractor's Name i/rG r-I nl License Business Phone Contractor's AddresS6, / , Sccu.�i S /c�aL /L-et_� Emergency Phone .Te,'$ oa 6 T !S RC1 Is Certificate of Wa7klnan's Compensation Insurance on File With SJLHD? Yes No ✓ U� W TYPE OF WORK (CHECK): NEW WELL;I DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ) WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ f REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank IoQ-5 Sewer Lines 144 Pit Privy Sewage Disposal Field /14� Cesspool/Seepage Pit NOAH e— Other Property Line�i'((OIR7 Private Domestic Well 00 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL XCABLE TOOL Dia. of Well Excavation Z.2. ,+� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �� a ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <'e n-+ e ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: i r PUMP INSTALLATION: Contractor f� o //Ail Type of Pump er^ke- le v S'/llh, - H.P._ . PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well 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 G _.-. ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 3 Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f 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." 1 ill call for a Gro Inspection prior to grouting and a final inspection. / r Signed X �� Title: C- _6_ Date: / �"- (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASES Application Accepted By d Date D Additional Comments: J_e 4 ' r ew,4e Phase II Grout Inspection ase Ul F' at pection 1 Inspection By Date Inspection By016=0 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received BJanuary 37 [3 July 1 R Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ .0� AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT b FEE + LESS PRORATION PLUS PENALTY r OTHER OTHER Received b7 Date Receipt No. it N Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201