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FOR OFFICE USE: APPLICATION IOiN .Non-Transferable, Revocable, Suspendable) •/ PUMP&WELL ENVIRONMENTAL HEALTH PERMIT // (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 w�nitTh San Joaquin County Ordinance No. 1862 a��ndgqtha rules and regulations of the San Joaquin Local Health District. Exact Site Address/�aC�7�a �'e 66u- e/�CY City/Town 4 Nom- � Owner's Name C.l'-r-%f' � ;� ��_e�/ L-O Phone s —-5,410C-72-3 Address spa City Contractor's Name License A38-'Y?/ Business Phone Contractor's Address _ � (��l�.nR Z- Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN,❑/' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION.IIJ� PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well TENDED USE TYPE OF WELL INDUSTRIAL CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER . (� Other Information ❑ GEOPHYSICAL :�Z Surfs_ c6 Seal Installed By: b PUMP INSTALLATION: Contractor Type of Pump' —<L-14-t— H.P._3 Q PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done `h,c 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, 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will c r rout Inspe ion prior to grouting and a final inspection. Signed X gbQ Title: t tt - Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT US 0 Y PHASE 1 Application Accepted By Dale 4 ' Additional Comments: Phase II Grout Inspection Ph se I final Inspection p Inspection By Date .Inspection B ® i / Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE j .REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE Li LESS PRORATION PLUS ' PENALTY OTHER OTHER 4 Received by Date Receipt No. ermitlow. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201