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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplrcallon. 'FOR OFFICE USE: APPLICATION Aw- 1"' (For Non-Transferable, Revocable,Suspendable) P(1MP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY W alth Districtfora permit construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local He made in compliance with San Joaquin County Ordinance o. 1862 and the rules and r gulations / the San Joaquin rd.HNeatth District. Exact Site Address it�1R City/Town • n c.1 ..Q � � `- Phone �.�`�/— �r% Owner's Name ` 'vi -1 1C 77 5 1� City — Address Contractor's Name L License#Z.3 51113 Business Phone Contractor's Address �� £ ''� 1 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL Ni DEEPEN 13 RECONDITION 11DESTRUCTION❑ WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR-0 also REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit P Other Property Line 16--Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL f ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ❑ DRILLED Dia, of Well Casing DOMESTIC/PRIVATE 4 + i f ElDOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 14 ROTARY Type of Grout El DISPOSAL 11OTHER Other Information 11 GEOPHYSICAL o--� Surface Seal installed By: G+fC C } 1 I PUMP INSTALLATION: Contractor el Type of Pump ' 1'' - H.P. , . PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR:, ' 1% 13State Work.Done "Z `�._t;zj,� -^#� r*e11 Approximate Depth DESTRUCTION OF WELL: 1 Well Diameter P Describe Material and Procedure i �r � s ter;�� .rr�-I� j I hereby certify that I have prepared this application and that the work�*ill be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the Sante-Joaquin Local Health District.l. Homeowner or licensed agent's signature certifies the following:`yl certify that in the performance of thework for which this permit II is issued, I shall not employ any person in such manner as to become.subject to workman's compensation laws of California." 4 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work"for which this Et permit is issued, I shall employ persons subject to workman's compensation laws of Califoinia." 1 will call for a Gro t Inspection prior to grouting and a final 1 spectio N Title: Date: SignecN r > S �i!_ j i—,(Draw Plot Plan on Reverse $ide) OR D ARTMEN USE ON Y PHASE I t Date Application Accepted By = Additional Comments: a e Ilk Final Inspection I Grout Inspectio +� Inspection By !'+ Date "" ` Inspection By Date I � " r Fee IS Due' ❑ ANNUALLY- ❑ PER UNIT PER 517E VIC ❑ EACH ❑ January 1 &Rec ived By January 31 ❑ July 1 &Received By July 31 k REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT fl 1 FEE . Lessa''^� PRORATION �. PLUS ` PENALTY OTHER OTHER q . 1 IDate Receipt No. "Permit No Issuance Date Mailed Delivered Received by L APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE:,P.O.any 2409 -STOCKTON,CA 952Q1 -