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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y FOR OFFIC8 USE: _ - max; " APPLICATION (For Non-Transferable, Revocable,"Suspendable) PUMP&WELL .. ENVIRONMENTAL HEALTH PERMIT _In (COMPLETE IN TRIPLICATE) I WATER QUALITY,,, Application is hereby made to the San Joaquin Local Health District forapermittoconstruct and/orinstallthe work herein'described.this application is made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 1 1� C-'t��Pr- 1Z City/Town Owner's Name b is y c7A/ 3'Ur rs y� Phone 93 Address �/ `f r'_ :-P-TTL er .eeA, s:f.• <^ :: City d I Contractor's Name .2,45jen-S License#a67'�05 Business Phone_ Contractor's Addressr}°/v2C� LV j f coyc ' 'kms.:? _. STt�c kir} Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes /%"�_ No 1 TYPE OF WORT( (CHECK): NEW WELL -DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION El WELL ABANDONMENT E] OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ f DISTANCE TO NEAREST: Septic Tank —,r ewer Lines �G� _ Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well}Nlfhk Public Domestic Well INTENDED USE TYPE OF WELL �$ ❑ INDUSTRIAL ❑ CABLE TOOL.,, ..�. ..- Dia'..of.-Weil-Excasiation, DOMESTIC/PRIVATE DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVELI PACK Depth of Grout Seal STC) 11 CATHODIC PROTECTION -, ROTARY Type of Grout C ' lT F ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL It Surface Seal installed By: e062 at-0 Lk)Q L-L- b,-L-LLg PUMP INSTALLATION: Contractor l(y\Qo- iM ati1 s L0,?4_Tei- S Type of Pump Sub IMei—SH.P. o� v, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 11 State Work Done DESTRUCTION OF WELL: Well Diameter .. Approximate Depth Describe Material and Procedure k� 't 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 eertifies'the following:"I certify that in the performance of the work for which this permit I 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to;workman's compensation laws"of California." I VdUciaK ta Gr 1 1 ection prior to grouting and a final inspeOeSide) - k i Signed X Title: Date: 70, (Draw Plot Plan on Re Title: c G FOR EPARTMENT USE ONLY F 02R 1EA21 PHASE I I �, Application Accepted y I Dat Additional Comment : ) ° _Phasqlvogt t 1 tio= Phas 11 Final Inspection Inspection By 1 % ' Ite r ��Z' Inspection By Date .� 1 ` I• ? Fee IS Due: ❑ ANNUALLY [:1 PER UNIT ❑PER SITE ❑ EACH ❑ January 1 &Received�By January 31 ❑ July 1 &Received By July 31 I REMIT BILLING REMITTANCE $. BASE "'EXPLANATION';, r AMOUNT DUE. CHECKED DATE ;DATE REMITTED AMOUNT FEE 6 8 C) LESS _, F PRORATION kk PLUS F PENALTY OTHER OTHER F Received by - Date .ReCeiptNo.;. _ Permit No. Iss ance D to Mailed Delivered . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201