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donsWill Be Processed i.6j Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 11'1L 2 19 $ APPLICATION ` .3 V (For Non-Transferable, Revocable;Suspendable) PUMP&WELL SAN JofQUIN LMWLA0NMENTAL""HEAI.TH PERMIT (COMPLETE IN TRIPLICATEkiLAL I H DISTRICT .WATER QUALITY,;h,, tcl Of l'-sin0", Application is hereby madeto the San Joaquin Local Health District fora permit.to construct and/or install thework herein described.This application is made in compliance with San Joaquin Co my Or finance No. 1862 and th r es and regulations of the San Joaquin Local Health District. Exact Site Address �53 � y ' r� n10�� City/Town _ kOwner's NameL� 1�i(.1�_,r� -.w Phone e'"r Address -� tom` tXti 1"'u r' .;? r�,. ,sn sF City r r .. P Contractor's Name �, S,.oLld License#r !�{ Business Phone- ~a I Contractor's Addressn o�� t `/1'JA 1N` Y`' Emergency Phone (CHECK): NEW WELL❑ 1 A TYPE OF WORK (J�1 r _ _ Is Certificate of Workman's Compensation Insurance on File _ S - � DEEPEN ❑ 4 RECORECO Yes a.1NDITION❑ �- DESTRUCTIOIO N❑ WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPCACEMENT 21 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy j Sewage Disposal.Field Cesspool/Seepage Pit Other Property-Line _ Private Domestic Well Public Domestic Well # INTENDED USE i TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation OR DOMESTIC/PRIVATE � i ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a ❑ IRRIGATION Y ❑ GRAVEL-PACK Depth of Grout Seal ` ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: Ik PUMP INSTALLATION:' Contractor Type of Pump H.P. PUMP REPLACEMENT: ``" " `®'State Work-Done. 11�_ =Lc,%Tg4 �'c PUMP REPAIR: ❑ State Work Done DESTRUCTION_ OF WELL: Well Diameter } Approximate Depth 4 Describe Material and Procedure F • Ll' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 41 ordinances, state laws, and.rules and regulations of the San Joaquin Local Health District. Home owner 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 tot workman's compensation laws of California." ° E I wi all far a Grout esti prior 10 grouting and a final inspecti Signed X Title: Date: 22 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY � PHASE! .i - �ti� �f'0. LL� Date -F Application Accepted By "A Additional Comments_ 'Phase At r 1 Inspection PhAse III Final Inspection p y- f h Date Inspection By Date �lJ Insection B -- E { Fee Is Due: ❑ ANNUALLY " "❑ PEH'UNIT* 'Cl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ih REMIT I BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE' DATE REMITTED AMOUNT FEE' E LESS e PRORATION ' PLUS e .+ ! PENALTY OTHER i OTHER Received by - Date - Receipt No.� Permit No. -- ,Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �_ „Rg