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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OF,EICE USE: II APPLICATION fir.- r (For Non-Transferable,Revocable,Suspendable) t l ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) Il WATER QUALITY ' Application is hereb/made to theSan Joaquin Local Health Districtfora permitto construct and/orinstall thework herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaglit n Local Health District. OF11 Exact Site Address o°Z9�S i / �tir•�( L.�c�/�. City/Town Stat-/P Ya'7+.�' Q Owner's Name 10 f° • A IQ e-ke S•G'S Phone 'Z- Address R L ywC city e. 2rr '. !-1 Contractor's Name ZAL t a 0 01 A 1. License If;Z 7/ Business Phone ' Contractor'sAddress�� LIG, aJ'd /9/H,ZK&aI Emergency Phone Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 ' REPLACEMENT❑ & , DISTANCE TO NEAREST: Septic Tank bd ti� Sewer Lines &%.4 A 7 Pit Privy Sewage Disposal Cesspool/Seepage Pit Other o Property Line Private Domestic Well AgAA Public Domestic Well AA 04_—/ INTENDED USE If TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Die.of Well Excavation _ ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ($'IRRIGATION I" ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION II ❑ ROTARY Type of Grout _ ' ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICALI Surface Seal Installed By: M PUMP INSTALLATION: !I Contractor bAz a e&P! PA,(4 Type of Pumo. .�Ts, tPUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Q Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County 'd ordinances,state laws!i and rules and regulations of the San Joaquin Local Health District. ' Home owneror 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-" Conirador's hiring or siib-contracting signature certitiea the following:"I 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 I call fm a Grout Iris! prior to grouting and a final Inspect Signed X t oEnA Title - Dale: 2 (Draw Plot Plan on Pieverse Side) ' FOR DEPARTMENT USE ONLY PHASE{ (/�_ Application Accepted By I� "'' �� . - Date V lt,Additional Comments: h �clf u C� = �rta4 �- Phase 11 Grout Inspection P.fa1s foal Inspection �• �l Inspection By a Date Inspection By-'A7 � Date !�•/ ��y F{{ ' Fee IS Due_❑ ANNUALLY I ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 A Received By July 31 REMIT _ I' BILLING REMITTANCE S BASE 11 FJ(PLANATION AMOUNT DUE CHECKED II DATE DATE REMITTED AMOUNT ' FEE LESS PRORATION II ' PLUS II PENALTY OTHER OTHER ,I 'I el =-A Received by Dates Receipt No. Permit No Hsuence bate Mailed Delivered APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITISERVICES 1501 It.HAZELTON AVE.,P.O.eoi M09 STOCKTOM CA SM01