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' Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. FOR OFFICE USE: R APPLICATION oc ' ; d (For Non-Transferable,Revocable,Suspendable) ^v d PUMP&WELL I!I ENVIRONMENTAL HEALTH PERMIT y (COMPLETE IN TRIPLI(ATE) �i 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 with San Joaquin-!Countrrdinance No.1862 and the rules and regulations of the San J�ogquin Local Health District. Exact Site Address ,d, r1�y S ` i�4_[ ..�g n fed City/Town ' Owner's Name /-� Phone Address - City SzJachAc... kC26 Contractor's Name License flgMi(A Business Phone Jff,"-.ZIP/d t Contractor's Address Emergency Phone I ' Is Certificate 61 Workman's Compensation Insurance on File With SJLHO? Yes_X No TYPE OF WORk:(PHELk)-l;r NEW WELL DEEPEN 11RECONDITION13 DESTRUCTION❑ WELL CHLORINATION'd. ; 'N/ELL' ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT 11 t•`"': :� DISTANCE TO NEAREST: Septic Tank lod I:(- Sewer Lines Y/DA fT Pit Privy ) Sewage Disposal F�Id. 16r] l.I Cesspool/Stepage Pit ""� Other 1 Property Line /O�! Private Domestic Well ss2-k Public Domestic Well �— INTENDED USE I TYPE OF WELL ❑ ,��({ INDUSTRIAL I°I CABLE TOOL Dia.of Well Excavation r � ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing 4 _ '❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal —� L-I CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 1 '❑ GEOPHYSICAL R Surface Seal Installed By: a",Aegcz �r PUMP INSTALLATION: 1 Contractor Type of Pump_ H.P. PUMP REPLACEMENT: ❑ State Work Done (� PUMP REPAIR: ❑ State Work Done u 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 thework forwhich this permit D F is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." S Contractors hiring or sub-Contracting signature certifies the following:"I certify that in the performance of the work forwhichthis S permit is issued, 1 shall employ arson s ject to workman's compensation laws of California,' FV• r 1 wit a Grout I esti prlo grouting and a final inspection. r j 'Signed X Title: Date: '1014A /—E�— (Draw Plot Plan on ReverseSlide) i FOR DEPARTMENT USE ONLY t PHASE I I !4•ft�L!/ t Application Accepted By irOt Date 31$lRD 4 ' Additional Comments: Phase 11'Grout Inspection Ph a 111 Final Inspection d,- Inspection By :I Date Inspection B. ate Fee Is Due: ElANNUALLY EXPER UNIT 11PER SITE 1:1EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 Bfl DATE _ . REMI�'TANCE REMIT S BASE EXPLANATION_. DATE DATE `' REMITTED P AMDUNT DUE CHECKED 9' } AMOUNT j ' FEELESS PRORATION aS 3 v PLUS r, -�•'— ' PENALTY OTHER l ^ .. OTHER .N. '•iJ �Recelvetl ty Dare .�f� : ' •""'Recelpt No. PermlrNS""'— � Issance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES -11601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201: .,