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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 (COMPLETE IN TRIPLICATE)t.L3�3y_ E�f-f t*f�W�4 �E�QUALITY 023r— 1 �� Application is hereby made to the San Joaquin Local Health District fdrerpermit toconstruct and/or instal I 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_1/M/ LJi�il/� rif�l�°E`AOR 3ou`iS/. G l�/Wi�//Z—City/Town Owner's Name �S,r L "L IE Phon,(Z7� 4¢7— 44S/ i Address /// l''tL1,iGlE� C�I�CG City �iS�C.�✓�GL� Contractor's Name 0/aSo/v 4II566,, License# O' Z,Business Phone Contractor's Address '�d1LC '/tiJ'�7f17S Emergency Phone w Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—; No W W ` TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ti WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ V DISTANCE TO NEAREST: Septic Tank 14140A44F Sewer Lines /fL'QrlEt>r`� Pit Privy •--�� i Sewage Disposal Field Cesspool/Seepage Pit Other { Property Line '3� ` Private Domestic Well Public Domestic Well — — INTENDED USE r}Fr TYPE OF WELL — ❑ INDUSTRIAL -- .'�CABLE TOOL_ Dia-of Well Excavation N F/.QST— i �- — Z'DOMESTIC/PRIVATE. O'DRILLED ^� "—^Dia'of Well Casing ❑ DOMESTIC/PUBLIC y 0 DRIVEN Gauge of Casing �4 I I ® IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information . ❑ GEOPHYSICAL Surface Seal Installed By: GI�se-� PUMP INSTALLATION: Contractor Type of Pump '5�1?51 H.P. PUMP REPLACEMENT: ❑ State Work Done `xj E, PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: Well Diameter Approximate Depth ' Describe Material and Procedure 1I E I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I G 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 1,r, is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ti Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." �. I will qall for a Grout Inspecti n prior to grouting and a final inspection. C Signed X _Title: a Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY +�' m ,. PHASE 1 Q i Application Accepted By Date Additional Comments: E has. II rout Inspection , 1 f ase NI spection fi Inspection By Date V Inspection By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT 00 a +}} FEE f LESS tk PRORATION PLUS PENALTY OTHER 4 f OTHER - -s �. V� �111�'3 -3L431) - 1 �. rpum-�-.�`� 1-/2 9Aq 3 Received by Date . Receipt No. Permit No. Issu nce Oate - Mailed - - Delivered - APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 16011E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201