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oozedn Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: ( C-i APPLICATION 17- S A S . M (For Non-Transferable, Revocable, Suspendable)-"�/,� PUMP&WELL. f ENVIRONMENTAL HEALTH PERMIT /117`Pe g� � 7 t� COMPLETE IN TRIPLICATE) WATER QUALITY W �ppl ication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applic do is Trade in compliance with San Joaquin County Ordinance No. 1862 and the rues and regulations of the San Joaquin Local Health District. xact Site Address < s35S g� City/Town S"fDLI ri�-A . - Phone Owner's Name 1 ba �On S Address 0 city Contractor's Name License# � _ �- Business Phone L2-- - ) i Contractor's Address 2-LA )�� Tr�dtll-- 1 Emergency Phone 3 Qin Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_tz� No TYPE OF WORK (CHECK): NEW WELL C] DEEPEN ❑ RECONDITION El DESTRUCTION❑ WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR ; t REPLACEMENT❑ ; DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Pit Other ool/See a e Cess Sewage Disposal Field p p g , Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 'IRRIGATION CU ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTIO7 ❑ ROTARY Type of Grout i ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P, I PUMP REPLACEMENT: ❑ State Work Done 11 State Work Done f PUMP REPAIR: I 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. °4 l Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this ersons subject to_workman's compensation laws of California." permit is issued, I shall employ p cal or a Grout Inspect! or to routi and a final in77 �� �� Date.Signed X Title: (Draw Plot Plan on Reverse Side) FO DEPARTMENT E ONLY PHASE 1 .29 ! aiion Acce By Date -�' Applic tt?d p Additional Comments: Phase 11 Grout InspectionP ase II Final Inp{pection �T Inspection By Date Inspection By//, - y ;7Date V Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE ti=xPLANATION BILLING REMITTANCE $ 4 AMOUNT DUE CHECKED TE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 3377 03 1 / L't!7 Received by Date Receipt No. Permit No issuance Date Mailed Delivered 1SR Te' ENV-11M dENTAL HEALTH PERMIT/SERVICES �_16Q3�.1�ELTO�N AVE.,P.O.Bo=2009 STOCKTON,CA 952 1 c