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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICAT IiiF,V "' C� (Fpr Non-Transferable, Revo I s i y PUMP&WELL ENVIRONMENTAL H l H PERMIT /Z, I (COMPLETE IN TRIPLICATE) WATER QUALITY J ON 16 1981 � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install ggthe work herein described.This It is made in compliance with San Joaqui County(Ordinance No. 862 and the u s an$l ulall`ioA-ZP' ne 9ar� In Local Health District. Exact Site Address -.f �f Oz,L z/ $-{EAL'EK/" RI��.b� I _� Owner's Name ! Phone 9.(J Address C) City h Contractor's Name G] f' License#A-d � Business Phone- -3 C. t Contractor's Address f 'I Emergency Phone dpi C_^F(- 1J___ Is Certificate of Workman's Compensation Insurance on File 6th SJLHD? Yes v No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 00 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ t 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 ! ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r ❑ DOMESTIC/PUBLIC , 11DRIVEN Gauge of Casing 11 IRRIGATION----- ' - .❑.-GRAVEL-RACK Dept h..of_Grout-Sea l_ I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I 11 DISPOSAL ` ❑ OTHER!, Other Information ❑ GEOPHYSICALR Sur a Seal installed y: PUMP INSTALLATION: Contractor L� Type of Pump H.P. �f PUMP REPLACEMENT: State Work Done GG PUMP REPAIR: ❑ State Work Done dFu P' 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 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 w' all fpr a Gro t Ins ction prior to grouting and a final inspection. �J Signed X gLA� Title: Date: (Draw Plot Plan on ReverseloSide) l FOR DEPARTMENT USE ONLY PHASE I Application Accepted By lam^-' Date Additional Comments: Phase II Grout Inspection pftag III Final Inspection Inspection By Date Inspection I Date "• t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 BELLING REMITTANCE $ REMIT BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEELESS nL PRORATION PLUS j PENALTY f ' t OTHER d + OTHER, ! - Received by Date Receipt No, ermit Na_ Issuance Date Mailed Delivered APPLICANT=RETURN ALL COPIES TO: l ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON;CA 95201