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ApplicationsWill BeProcessedWhenSubmitted Properly CompltlWd'.-Be Sure To Sign The Application. FOR OFFICE USE-. APPLICATION t- (For Non-Transferable, Revocable, Suspendable) - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) Qg� F(;fC E Way, AT R-QUALITY 4_- �-7 —3'70� 1 O Application is hereby made totheSan Joa�inLocalHea4thDistrictora ermittoconstruct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules an�1 regulations of the Sari Joaquin Local Health District. Exact Site Address 'r9 �T 119�O �0 X10 t^� T City/Town _ )C:Z� H rit.odd Owner's Name . 121?e 4 Phone Address regP City Contractor's Name n..,� R.!/dA.e� F'm. License# > Business Phone � �/� Contractor's Address d') z Emergency Phone S — Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Arl No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT Il OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ (!1 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines 3oa l - Pit Privy _ftp_ Sewage Disposal Field Cesspool/Seepage Pit —rte Other Property Line Ze%.ka�Private Domestic Well :Sd ` Public Domestic Well `� I INTENDED USE TYPE OF WELL .f ® INDUSTRIAL —,' ❑ CABLE TOOL. Dia. of Well Excavation 1 ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /6o P-1'/ Ovo ❑ IRRIGATION GRAVEL-PACK Depth of Grout Seal S'0 ^C� ❑ CATHODIC PROTECTION "® ROTARY Type of Grout _ ( '�C� eN+7 Qr.,ng_- ` �O ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 1 Surface Seal Installed By: va cag,11A PUMP INSTALLATION: Contractor Type of Pump H.P. i PUMP REPLACEMENT: ❑ State Work Done _ PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure a 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 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 + i permit is issued, I shall employ persons subject to workman's compensation laws of California." I I will call for a Grout Inspection prior to groulling and a final inspection. ! Signed XTilte: Date: ' - a (Draw Plot Plan on ReArse Side) _ FOR-DEPARTMENT USE ONLY PHASE Application Accepted By ae Date Additional Comments: r , Phase II Grout Inspection Phase III Final Inspection / Inspection By R 49(6� Date 7 "I Z"��"r Inspection By Date Fee Is Due: ❑ ANNUALLY ::❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R11cei11ed By January 31_ ❑ July 1 &Received By July 31 j REMIT 7 BILLING REMITTANCE i $ BASE EXPLANATION DATE DATE ;. F REMITTED AMOUNTDUE CHECKED 07 AMOUNT 9 b FEE 443 �a I LESS PRORATION 4` "PLUS E ''ll - PENALTY tih ._ lnrl R-9 t-1 �PC'fr. I` u.rNlva �I s , L u 7 4 OTHER (/ Z �� hiu flQ yvU r��"P/,4&P I d q �{��_ r+� 'OTHER --- . U pf N r[ - Cf -If t C° r `- -1`•a _7/7/,7d 3 33 �Cv��— � �-7—� ` . L--t o! o�4 Received by- Date - Receipt No," Permit No. Issuance Date _ Mailed\ "Delivered �� 'i x APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009"— STOCKTON,CA 95201 .� 4 e