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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. -OR OFFICE USE: APPLICATION . (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 witSa Jj�jin C untuy Or mansce No. 1 and the ruses and regulations of the San Joaquin L al Health District. Exact Site Address *2- Ll !! �/�• IT�i VON"��;,/_ D ,� ` City/Town ,1��r(� j Owner's Name • IC, 1 ri 6A -bB� 1 [AI LAG40 Phone_ l-40 — 7 0 Address 12�• • �D11jlf}Z.D R4� City ] &Mi� S20 Contractor's Name C,L WOLL!ENCU;p. ��License# 4Z Business Phone GZ� Contractor's Addresses 414 E. 0;4&rA Lull Emergency Phone Is Certificate of Workman's Compensation In,,suraanc on File With SJLHD? Yes—L-- No TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ l / DISTANCE TO NEAREST: Septic Tank fLQQ t Sewer Lines ��li� Pit Privy Sewage Disposal Fi?ald /!}4 1L Cesspool �/Seepage Pit Z&Yt z Other Property Line Private Domestic Well,Q rPublic Domestic Well Wak(!P, INTENDED USE TYPE OF WELLIO N C3 INDUSTRIAL 11 CABLE TOOL pia. of Well Excavation ❑ Dgy4E5TIC/PRIVATE C3 DRILLED Dia. of Well Casing 4 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing CL /bd PU - O ❑ IRRIGATION ❑ G PACK Depth of Grout Seal b s S ❑ CATHODIC PROTECTION ROTARY Type of Grout �,ff0�lTF. ❑ DISPOSAL ❑ OTHER Other Information n ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 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 f 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will II fora out Ins tion nor to grouting and a final inspection. Signed Title: �_ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE / Application Accept,, Date / Additional Comments: Phase II Grout Inspection h se II Final Inspectio ,,-7- Inspection By Date Inspection B Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Receiwed by tDate Receipt No. Permit No. issuance bate I Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .� f