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FOR OFFICE USE: 1 vLWPPLICATION 4�!f@*n-Transferable, Revocable, Suspendal, J r`` PUMP&WELL p ENVMENTAL HEALTH PERM IT` (COMPLETE IN TRIPLICATE) S�'i� Y�n .t s` lIR�41�-� WATER QUALITY = Application is hereby made to the San aa 1 strict fora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the ules and regulations of the San Joaquin Local Health District. Exact Site Address - =irl nJAJ 4,L—WR b - City/Town ___L_C>E)t' Owner's Name 0117 1 phone Address i -- City O Contractor's Name A>1ZTI,,Ly R_ otzU,,.� D�, ,,o6 - License#C�3Gi3 i� Business Phone,20ei — l Contractor's Address — Emergency Phone Is Certificate of Workman's Compensation Insurance on eile With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRN REPLACEMENT a� � l DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i Property Line Private Domestic Well Public Domestic Well INTENDED USE w TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ r� ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ZC7 J, _ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ! q " C C,i2 E�A2 .' ❑ IRRIGATION1� WH.GRAVEL PACK Depth of Grout Seal aep r , CATHODIC PROTECTION VROTARY Type of Grout ;PAE/Z ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: , PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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, 1 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 forwhich this permit is issued, i shall employ persons subject to workman's compensation laws of California." I. i I will call for a Gr nspectioq p for to grouting and a final inspection. Signed X Title: -- 1t1r Date: (Draw Plot Plan on Reverse Side) Tr FOR DEPARTMENT USE ONLY PHASE I _ Application Accepted By Date l Additional Comments: Phase II Grout Inspection Phas II! Finat Inspection +.a Inspection By Date Inspection By 9r�/7 Date Fee Is Due: El ANNUALLY [1 PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑�y 1 &Received By Jury 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUOT FEE Pd. a LESS PRORATION PLUS �1 PENALTY OTHER 1 OTHER R Receive Datel Fleceirit No. Permit No, Issuance Date Mailed Delivered r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 1