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4Applfcatlonfbr Processed ubmitted Properly Completed.fie Sure To Sign The Application. FOR O�ICE U§ 17982 vrrYY 1 7982 APPLICATION 14N Jn�;0U (For Non-Transferable,Revocable,SuspendPUMP WELL !/ ' %!i' ;N � � — 4LTr LCCA 'iR MONENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) i ��S7-RWT WATER QUALITY Applicatiun is hereby made to the San Joaquin Local Health District lora permit to construct and,or install the work herein described.This application Is made in compliance withSanJoaquin Count O finance No. 1862and the rules anp regufations of the San Joaquin Local Health District — Exact Site Address --T Phone tttrO�j,o,1 , A1Ju. 2/ EcJ City/Town / Owner's Name --L�./YJ- IIOGPh D�I Phone -._ 969-1,236 City—Address --—— 9. - City-- - --- - p p -A Contractor's Name .4tA(7 /'qv License a DOI? Business Phone-, Contractor's Address __ �j—/i�x�r.$/nEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes n No , TYPE OF WORK (CHECK): NEW WELL V DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION L7 PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank nnnn --�`� Sewer Lines -___ ._ .-_ _ Pit Privy Sewage Disposal Field--_1�/ 3�_ Cesspool/Seepage Pit __- __- Other wL�ro� Property Line _ Private Domestic Well _ _ _ Public Domestic Well INTENDED USE TYPE OF WELL ❑SfVDUSTRIAL ❑ GABLE TOOL Dia.of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ pRIVEN Gauge of Casing . _ 13 IRRIGATION RAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout — ❑ DISPOSAL ❑ OTHER _ Other Information ❑ GEOPHYSICAL Surface Seal Installed By: �7 �) 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-eii.fy 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. Home owner 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." I Contractor's hiring or sub-contracting signature certifies the following: 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 wi call for a Grout,lnsp on prior to grouting and a final Inspectio / 1 Signed X �1 —L -- ' ' �L --- Date: C/! L?��— r w Plot Plan on Reverse Side /// FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By Date Additional Comments: Phase II C+r I nspection Phase III Final Inspection / Inspection By i _ te__-C �L3-_�SZ_ Inspection By Date 1�—Z�ZL ��-- Fee Is Due:❑ ANNUALLY ❑ PER UNIT PER SITE ❑EACH ❑ January'1�'Q-�Received By January 31 ❑July 1 6 Received By July 31 1 BILLING REMITTANCE I S REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE �` — --- - - ----- ��3 -- LESS — PRORATION PLUS PENALTY OTHER OTHER - OTHER ' /s79E -- Heceired by Date Receipt No ------Permit No Issuance Date Marled Delivered— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201