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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. FOR OFFICE USE: 45P LICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San,Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address fre—ZlCh "apt Fid .—1 mi le best of 1-w City/Town north sid - 1mileR it Owner's Name joe MMriihe 3ti Phone 982-081+3 Address 1207 Z. 11 T ine Ave. City 6LOCkt71')5. Ca Contractor's Name Lenni 1.2,75 rr0,. Drilling CCLkense# 29081 3 Business Phone 1��1—� 1 S ` I'n Y i Contractor's Address } Emergency Phone 545--02 zi Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1,Mi. Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2711 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� ❑ DOMESTIC/PUBLIC ❑DRIVEN Gauge of Casing IRRIGATION QGRAVEL PACK Depth of Grout Seal. v'n ❑ CATHODIC PROTECTION ROTARY Type of Grout _17 ❑ DISPOSAL ❑ OTHER Other Information_111alb—by Z• ner ElGEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: 4 Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth I0 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 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X Rennin s Bros. By Ttie / � Date: (Draw Plot Plan on Rever Side FOR DEPARTMENT USE ONLY PHASE I 1 Application Accepted By Z f. _ Additional Comments: / - Date-41 Phase 11 Grout Inspection r r Phase III Final 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 1AEMITTANCE - �s - REMIT BASE EXPLANATION A DATE DATE REMITTED MOUNT DUE CHECKED AMOUNT FEELESS r / PRORATION " PLUS PENALTY OTHER OTHER Received by ..-Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.B.6or 20p9 STOCKTON,CA 99201