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peny Applications WillBe Proceed When Submitted ro ,` y-t. APPLICATi01 FOR r?,FFICE USE: (For Non-Transferable,Revocable,S.4endable)� � � pUMP&WELL l } t _ ENVIRONMENTAL HEALTH PERMf oci; � WATER QUALITY t1`' " ' {r-.? l:'`;-.:l� qih location is (COMPLETE IN TRIPLICATE) i, ai cation is hereby made to the San Joaquin Local Health District 2 a dPhe rules and a tulatdO rs San` Jpageut.1-10cal Health District. s Application dr.1�' c 'I made in compliance with San Joaquin County Ordinance No. city/Town 1 13 a. 9 L � Exact Site Address phone Owner's Name City �` 3 AddressLicense#L&I� Business Phone Contractor's Name p# ' Emergency Phone f ,} Contractor's Address `� NO ~� d Is Certificate d Workman's Compensation Insurance on File With"SJLHD? Yes ❑ DESTRUCTIONO TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION CHLORIN N ❑ WELL ABANDONMENT � OTHER ❑ PUMP INSTALLATION� PUMP REPAIR❑ WELL CHLO i REPLACEMENTPit Privy ,Sewer Lines Other DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Sewage Disposal Field public Domestic Well Property Line Private Domestic Well K TYPE OF WELL INTENDED USE.. Dia. of Well Excavation ❑,rNDUSTRIAL [1 CABLE TOOL- 6 d ❑ DRILLED Dia. of Well Casing DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing 11 [3DOMESTIC/PUBLIC GRAVEL PACK Depth of Grout Seal '❑ IRRIGATIONI Type of Grout t E313 ROTARY CATHODIC PROTECTION ❑ OTHER 1 Other Information 1 13 DISPOSAL Surface Seal Installed By: ICAL ❑ GEOPHYSICAL I Contractors �..: -- _ `-H.P. PUMP INSTALLATION- r..��: --� ,r- __�� ,------ Type of Pump L'State Work Done I PUMP REPLACEMENT: ❑ State Work Done r PUMP REPAIR: Approximate Depth DESTRUCTION OF WELL: Well Diameter . �- Describe Material and Procedure. I hereby certify that I have prepared this app lication 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 Healthy performance i . Home owner or licensed ag ent's signature certifies the following:"I certify that in theorkmn's compensation the work forwho aws f this permit_ I shah not employ any person on such manner as to become sub�[Ift thallor't in the per#ormanceof the lwork forwlh ch this !, is issued, g:` Contractor's hiring or sub-contracting sign subject to re ,workman's compensation laws of California." permit is issued, I shall employ p s I wit 11 for a Grout In ction prior to grouting and a final inspection. pate: _ Title: Signed X '-(Draw o anon Reders Side} � FOR DEPARTMENT USE ONLY ' I � �. Date F PHASE l Application Accepted By Additional Comments: phase III Final inspection Phase 11 Grout inspection Inspection By Date Date .. Inspection By Jul l &Received By July 31 ❑ EACH ❑ January 1 &Received By January 3i y REMIT PER UNIT ❑ PER SITE $ CHECKED Fee 15 Due: ❑ ANNUALLY ❑ BILLING REMITTANCE AMOUNT DUE DATE REMITTED�:,. � AMOUNT BASE EXPLANATION DATE FEE I' ` LESS PRORATION PLUS PENALTY OTHER ; OTHER - A t i Mailed Delivered Permit No. i suance Date Dal" a eipt o. 1601 E.III AVE.,P.O.Box 2009 .sTOCKTON,CA 95201 �- ` - tReceiv y - APPLICANT—RETURN ALL COPIES TOr ENVIRONMENTAL HEALTH PEAMITlSERV10E5 !