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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—10 `�_qs N• L W&, $4CQ*H&_JJn UD City/Town utra)a Owner's Name T 'RDGL Phone 9 ��2sWerk:fj�V-7 " �i 3G - ' ��-zd9/ Address I wAn�,,�� 4C City Contractor's Name CL' AGI( WELL EL�License#17� Busil hone �.Z' Contractor's Address 'LO 23 E- C I!T Emergency Phone A017-! _ _ Is Certificate of Workman's Compensation I�nsuran��an File With SJLHD? Yes L-___1 No TYPE OF WORK (CHECK): NEW WELL IL� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank ea Sewer Lines IQ�'t Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Wel! Public Domestic Well INTENDED USE TYPE OF WELL ❑ !N& STRIAL ❑ CABLE TOOL Dia. of Well Excavation `QN DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing IG ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '' h+ 11 IRRIGATION ❑ G L PACK Depth of Grout Seal �� 11 CATHODIC PROTECTION ROTARY Type of Grout �>♦�� ❑ DISPOSAL ❑ OTHER Other Information ; ❑ GEOPHYSICAL Surface Seal Installed By: 11 , PUMP INSTALLATION: Contractor H Type of Pump H.P, PUMP REPLACEMENT: ❑ State Work Done a (" PUMP REPAIR: ❑ State Work Done �a DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ti I hereby certify that I have prepared this application and that the,work will be don';'in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. _k" i.-; Home owner or licensed agent's signature certifies the following:"I certify that in the performarfce of the work for which this permit IA 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 certifythat in the'performance of the work forwhichthis permit is issued, I shall employ persons subject to workman's compensation laws of California.'.. I will call for a Grou Inspection or to grouting and a final inspection. AASigned X Title: V u1g Date: 3 V n,* (Draw Plot Plan on Reverse Sidd) r f' FOR DEPARTMENT USE ONLY 6 �r PHASE IC - Application Accepted By- Date `fes Additional Comments: hase U Grout Inspection ase Ili Final Inspection -~ 'Inspection-By _Date —Inspection By Date- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ,b F= �H ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATIDN AMOUNT DUE CHECKED DATE DATE REWTTED ,�#yy AMOUNT (__( FEE L 3 'L 3 LESS PRORATION ' PLUS PENALTY OTHER OTHER � s31 (� Received by Date Receipt No. Permit No, Ise ancelDate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201