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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si leApplication. FOS; OFFICE USE: APPLICATION MAY 4 1981 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN f0"`•U11N �-O-AL (COMPLETE IN TRIPLICATE) WATER QUALITY HE�,L I_H 01STRI0T 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 an th rules and regulations of the SanJoaquinLocal Health District, Exact Site Address S . ' City/Town IL17 _ Owner's Name 6 Phone—812!7—__oG Address City 6SG oi'll -� Contractor's Name License#.9 Wei 0 Business Phone 63 f-220-7 W Contractor's Address Emergency Phone /?►-e. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER U1 PUMP INSTALLATION IIS PUMP REPAIq,11t REPLACEMENT 1:1By) wAL..L Ta 6,e 'Te i-s[JM�r2R / OL) ©� L GR DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1 _ / `7 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 IR DOMESTIC/PRiVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor _ pp Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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. 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 wi II far Grou sp on prior to grouting and a final inspn. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI ©� Application Accepted By Date Additional Comments: Phase II Grout Inspection se III Final Inspection Inspection By� Date Inspectio y Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LI �- LESS PRORATION PLUS PENALTY OTHER OTHER �1 �6�.24Y -7 1�6� Received by Dae 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 95