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Applications Will Be Processed When Submitted Properly o s FOR OFFICE USE: APPLICATION 4 _ (For Non-Transferable, Revocable, Suspendable) PUMP&WELL I ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (COMPLETE IN TRIPLICATE)-7,30 0 S',.s'77j%cL) Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is y made in compliance with an.Joaquin County rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. S City/Town ��c--k—&-iv Exact Site Address c✓ � "� ' " — --� Phone Owner's Name City Ajg 2 Addressf �� / Business Phone #r -1y Contractor's Name J~1 itis p _ t�I_r�� License� J Contractor's Address / Emergency Phone No T'" Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL El DEEPEN RECONDITION❑ DESTRUCTION Cr WELL CHLORINATION 13 WELL ABANDONMENT El OTHER 11 PUMP INSTALLATION 13 PUMP REP1 . AIR❑ Cr f REPLACEMENT❑ I �0 1.� Pit Priv j : Septic Tank Sewer Lines y Y DISTANCE TO NEAREST I Sewage Disposal Field t Cesspool/seepage Pit Other Property Line� Private Domestic Weil,�i��1 Public domestic Well INTENDED USE TYPE OF WELL �! ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation fl ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing L: -[l�—� ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �- J ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout y ❑ DISPOSAL 11OTHER Other Information Aot ❑ GEOPHYSICAL. Surface Seal installed By: , -h PUMP INSTALLATION: Contractor H.P. Type of Pump ! PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure c t i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f� 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 thework forwhich 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 emplo persons subject to workman's compensation laws of California." 1 w' call for Gr Ins c on prior to grouting and a final inspection. Title: ;4'u Date: Signed (Draw Plot Plan on Rever Side) FOR DEPARTMENT USE ONLY i PHASE L Date —L-�-�/- p Application Accepted By r Additional Comments:. Ph 1 Fina Phase 11 Grout Inspection _ Inspection By Date inspection By ti ' ❑ ANNUALLY 11PER UNIT El PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ REMIT July 1 &Received By July 31 Fee Is DVe • BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANAT40N DATE DATE REMITTED AMOUNT FEE I I LESS PRORATION PLUS PENALTY I OTHER I OTHER- Received by Date' Receipt No. Permit No- Is ante ate Mailed Delivered 1601 E.HAZELTON AVE .P.O-Box 2009 STOCKTON,CA 95201 �$ ' APPLICANT—RETURN ., ALL COPIES TO:,,...ENVIRONMENTAL HEALTH PERMIT/SERVICES �"0✓