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• Appiis�aUon mlll-Be Processed When Submitted Properly Completed.Be!:rl red e T r Sign The Application._ - FOR OfFFICE USE: /M APPLICATION -- �dnfV!i (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT MPLETE INTRIPLICATE) !( (Q'y�:.L;. co?'� ,Go�P RQUALITY . t� .�,J t�7.- "lo -" , pplication is he made to the San Joaquin Local Health District fora permit toconstruct and/or Ritall the work herein described.This application is made in compliance with San Joagilin County�O/rd�I,nance No.1862 add the rules and regula ons of the San Joaquin Local Health District. Exact Site Address tJTv.=e �. < {�pL' ryly1�� 0&'m i, City/Town Owner's NameC'"�`�%' " a-xC< ✓ri.®5sv v "� Phone Address ^i c: '�• r a .. City ' �r5' -� Contractor's Name Q. ` .r License lY' -7 v'S"Business Phone 44C4T• Contractor's Address A0011W Emergency Phone Is Certificate of Workman's Compe�Aksation Insurance on File With LHO? Yes _ I No -. H TYPE'OF WORK (CHECK): - NEW'WELL 11DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR® C>b REPLACEMENT❑ Q DISTANCE TO NEAREST: Septic Tank Sewer Lines M' Pit Privy Sewage Disposal Field ;Cesspool/Seepage Pit Other j Property Line Private Domestic Well V Public Domestic Well INTENDED USE TYPE OF WELL _ ❑ 114DUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing •,+' 09 Iff IRRIGATION O.GRAVEL PACK - _ . Depth Of Grout Sealy _ 113� ❑ CATHODIC PROTECTION ❑ ROTARY T of Grout t'i ' 1 Type ❑ DISPOSAL - ❑ OTHER - Other Information ❑ GEOPHYSICAL �s Surface Seal Ins Iled B :✓'^i y.. PUMP INSTALLATION: Contractor CS'I`OtJQ]/� GQ'61- 1 Type of Pump.T _ 77-1 w h4,160-d" } a_ H.P.- PUMP REPLACEMENT: ❑ State Work Done - 4 MP REPAIR: - Iq State Work Done '� J0 An A s MMP OF WELL: Well Diameter _ Approximate Depth - -. . Describe Material and Procedure 1 Y I hereby certify that I Have prepared this applicatiorf and that the work will be done in accordance with San Joaquin,County i=t� ' ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. 111 `I _ hhhh Homeowner or licensed agent's signature certifies the following: certify that in the performance of the work forwhich this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California. 'zConiracioes hiring orsu}-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." y.. 41 N l call fora=Grout Inspecli no .torout %a d a-finalinspectlom- Signed _ tie: p-� f Date: (Draw Plot an on Reverse.Side) I �� FOR DEPARTMENT USE ONLY s' ' PHASE 1 '. Application Accepled.By Aate. Additional Comments: �^ • - Phase/1 Groh{Inspection a HI Fin ` Inspection By .Data Inspec' V Fee Is Due: ❑ ANNUALLY Q PER UNIT -❑ PEH SITE ❑ EACH,' ❑.January 1&Received ey January 31 ❑ July 1 a-RoeSived ey July 31 REMIT BASE I�j 4' 'E%PLANATION BILLING REMITTANCE $_.. r AMOUNTDUE CHECKED - CATE DATE : REMITTED AMOUNT I FEE . . .. .P 1i )Ili .7 LESS PRORATION " t PLUS PENALTY. OTHER OTHER 91 • "';.,,,M.. 1. .� ' - l" - Received by Date _' ...Receipt No.. r 'Permit No. - lastraripe MW . Mailed Delivered, ., r APPLICANT—RETURN ALL COPIE STO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.BPM 9009 ' STOCKTON,CA 9=1