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ptt nsWill BeProcessedwneI3L-i�mm�tea ProperlyL;ompletea. tse sure Iosign trteApplication, USE: , t10V ?4 1979 APPLICATION (For Non-Transferable Revocable Suspendable) I ffRINMENTAL HEALTH PERMIT PUMP&WELL HEALTH DlSSAN .�Ofi�l�lf�! -' 1`f (t; LETS IN TRIPLICATE) � ATER QUALITY ��—. /4 r�2 f -Application is hereby made tot h an�Jo q Wn Lo air eat tic a permit to construct and/or install the work herein described.This application i made in compliance with S n Joaquin Co my Ordinanc o2 and th s nd rgylulations of the SVan n Local Heal Di trict. Exact Site Address ;' " f r�� G A d� City/Town / Owner's Name !AIt�11TH aleti, rLLh 01 S Phone Address l3 L, 7 2 „r Az,;, #O A7(6� r��a a 13-32310 City Contractor's Name License 4- i Business Phone � �7 Contractor's Address .S/'� f Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No TYPE OF WORK (CHECK): NEW WELL.K DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ i REPLACEMENT❑ j I DISTANCE TO NEAREST: Septic Tank Sewer Line% 111il'- Pit Privy 1 Sewage Disposal FieyCesspool/Seepage Pit_. �'— Other I i Property LinePrivate Domestic Weil 7— Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE 9 DRILLED Dia. of Well Casing it ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d/ �� 1 ❑ IRRIGATION 1:1 GRAVEL PACK Depth of Grout Seal ' ❑ CATHODIC PROTECTION JR ROTARY Type of Grout , 2f 4!%MQ &Z- ❑ DISPOSAL ❑ OTHER Other Information © GEOPHYSICAL urface Seal Installed By: &Ck lieWA� PUMP INSTALLATION: Contractor .IQ -9 F Type of Pump H.P. 3 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 Describe Material and Procedure 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'h i ring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this J permit is issued, I shall employ persons subject to workman's compensation laws of California." I ill cal Gro nprior to grouting and a final inspe o Signed X s n Title: Date: (Draw Plot Plan on Reverse Sid F, DEP TMENT USE ONLY PHASE Application Accepted By Date Additional Comments: i Phase II Grout Inspection Pas li ilial 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 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEEr,4 O LESS ( I PRORATIONPLUS . PENALTYd OTHER OTHER (] Received by Date Receipt No. Permit No. lAuance bate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201