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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. -;FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) �-. ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (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 with San Joaquin C',-.C.00unty Ordinance No. 1862 and the rules and regulations of the San Joaquin Loc I Health D'strict. Exact Site Address .rte/c!5i r_,06 />"ca��_r�� _//��1 �+rc��r' City/Town -76 /: «+ .-7 Owner's Name-3, 4CCW12� � %G ��S'. De :� Phone Address r _ City /it, Contractor's Name 'W"Pre 0- /0-A L., "s r .r License# � � �� Business Phone fa-) X71-&'.?3.p Contractor's Address 7"v Emergency Phone is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL W. DEEPEN ❑ RECONDITION❑ DESTRUCTIONW, WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 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 r, ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED pia, of Well Casing ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 17� CATHODIC PROTECTION ROTARY Type of Grout CcF C 0 ❑ DISPOSAL ❑ OTHER Other Information GEOPHYSICAL Surface Seal Installed By: cores �- PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter �� _ A� r ximate Depth Describe Material and Procedure A0 N 1 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." call fo Grout Ins ection for to grouting and a final inspection. Signed X Title: /&K, rc Date: 1A0?.,6e`80 ; (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI r Application Accepted By Date E Additional Comments: Phase ll Grout Inspection Phase III Final Inspection Inspection By { � Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE REMIT BASE EXPLANATION DATE DATE R ED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER a �b sL/ 0 8s r � Received by IDate Receipt No. Permit No Is uance bale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201