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App ications Will Be Processed�bl+ Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: JUL - 6 1982 APPLICATION rr (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ' SAN JGr5Qi. IN L09MIRONMENTAL HEALTH PERMIT r 4 F (COMPLETE IN TRIPLICA7 } ALTH DISTRICT WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Tliisapplication 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 City/Town AM AOTE CA Owner's Name " Phone Address _._SAME �` .. City Contractor's Name CALIJJA License#22L2_-_? Business Phone Contractor's Address _:3 0 S. -k-JILA09V 7t4 Emergency Phone 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL% DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �} WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑, PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank . Sewer Lines Pit Privy � Sewage Disposal Field r-7 Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE --• - TYPE OF WELL I��i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE 7 ❑ DRILLED Dia. of Well Casing _d", ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _?VK 1160 ❑ IRRIGATIONr��GRAVEL PACK Depth of Grout Seal � ZZT _ 1:1ya CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL- Surface Seal Installed By: S PUMP INSTALLATION: Contractor Ir Type of Pump H.P. i PUMP REPLACEMENT: T ❑ State Work Done " PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe.Material and Procedure i 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 r 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 1i permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call JorA Grout Inspection prior to grouting and a final inspection. " Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I �. _ ., .. ,�.._. ..r• .--�... s »_. . Application Accepted By pate Additional Comments: l-l wrncd Phase II Grout Inspection /JD % hese III Final Inspection �1 y_& �iG��. O ,2ff—ff�. Inspection By Date Inspection By Date � u f . . . Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT 1 BILLING REMITTANCE $ ' BASE EXPLANATION AMOUNT DUE CHECKED ' DATE DATE REMITTED AMOUNT FEE LESS PRORATION F i PLUS i PENALTY tk� OTHERr Iry 0L OTHER - �Z rya r/;j �'SGb 12� lltn 1�'f J G rt t di J do�v '� o p'"c�•s.:6 Received by Date Receipt No Permit No. Is uance to_ Mailed Delivered ,•.,� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,F.O.Box 2009 STOCKTON,CA 95201 �J