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" =Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL " ENVIRONMENTAL HEALTH PERMIT �J WATER QUALITY l Y ( NS"f. (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework.herein described.ThisD i apptrio.cation is i made in compliance with S n oaquin County Or inance No..1862 and th rules and regulations of the San Joaquin Local Health District. i Exact Site Address 1 City/Town AQ C0;en Q 1 Owner's Name � Phone Address c A City v>*-> ' j I upkA # J SJ 2-3 Business Phone —1 Contractor's Name Contractors Address qy Phone a Is Certificate of Workman's Compensation.Insurance on File With SJLHD? f�Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION Ni WELL CHLORINATION 11WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION PUMP REPAIR© REPLACEMENT❑ �1� A } DISTANCE TO NEAREST: septic Tari k �� S wer Lines /V Q e[1C' Pit��P��r99ivy - --' —,--,Sewage Disposal Ficl� �_ Cess'eil/Seerade Pit Iv©A:' ` Other /� O �`' fff F ) Property LineMO Private Domestic Well�a-Public Domestic Well E INTENDED USE TYPE OF WELL Ir 6. ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation OMESTIC/PRIVATE DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal_ .�� 13 CATH ODIC PROTECTION ©'ROTARY Type of Grout Q111 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL / urface'Se�Itled B e'PUhAP'INSTALLATION: Contractor f I ' y f Type of Pump h 1A' r- H.P. i PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done t Approximate DESTRUCTION OF WELL: Well Diameter � A PP Depth _ P Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance wit__h San Joaquin County Y 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 employany.-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 ___issued, !shall employ persons subject to workman's compensation laws of California.""'""" y. Ql call-1oraGrout'� s estin-prior to•groutin ,and-a-final-inspection Signed X Title: Date: c (Draw Plot Plan on Reverse Side) f /� FOR EPART ENT USE ONLY - PHA$EI - . /Jtitec.�-� Date Application Accepted By Additional Comments: [ ' Phase It Grout Inspection Phase III Final Inspection Inspection By &• /? ' Date a Inspection By� -. Date Fee IS Due: 11ANNUALLY ❑ PER'UNIT' El PER SITE ❑ EACH - -❑ January 1 d Received By January 31 [I July 1 &Received By July 3 REMIT .-- r BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED+ - I DATE DATE REMITTED AMOUNT - FEE V `-) t LESS F PRORATION PLUS PENALTY OTHER ._...-OTHER Received by Date Receipt No. Permit No: -• Issuance Date Mailed Delivered r r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.;P.O.Box 2009 STOCKTON;CA 9S20