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._ :.:.. A , Applications Will Be Processed When Submitted Properly Completed:Be Sure 10 slgo I ne wpprmnn�u. _ ,�j APPLICATION FOR OFFICE USE: 'l (For Non-Transferable.Revocable,Suspendable) PUMP&WELL iENVIRONMENTAL HEALTH PERMIT j (COMPLETE IN TRIPLICATE) .^ WATER QUALITY ' Application is hereby made to the San Joaquin Local'Haalth District for a permit to construct and/or install the work herein described.This application is j made in compliance with San Joaquin County Ordinan a o.1B62 and t rules and regulations of the San Joaquin Local HeEkLth District. City/Town Exact Site Address . ' Owners Name n Phone Address City n Contractor's Nam a ? + License Business Phone ��.—.�e .� !'ice �+ Emergency Phone ) j Contractor's Address �/ No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 11 . WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR ' REPLACEMENT❑ - DISTANCE TO NEAREST: Septic Tank Sewer Lines Pd Privy .Other Sewage Disposal Field Cesspool/Seepage Pit ' Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia-of well Casing ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN - r Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information _[ El GEOPHYSICAL Surface Seal Installed By: - ' PUMP INSTALLATION: Contractor 1. H.P. n'^ Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done ApprexifBepth DESTRUCTION OF WELL: Well Diameter aete� Describe Mater al and Procedure I hereby certify that I have prepared this application end that the Orkwlll be done in a ordanc 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 cerillles the following:"I certiy.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." Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 1 w�cgtf fora Grout Inspection prior to grouting and a final inspectsyq a Q� ]C�/ f/i �l_!J Title:..... i,••4- Dale: G Signed X (Draw Plot Plan on Rev fee Sid ) ' FOR DEPARTMENT USE ONLY - PHASE 1 '3 Date Application Accepted By F-+ --- 4 Additional Comments: Phase II Grout Inspection �Phas�a III Final Inspection 11 Inspection By Date Inspection By �Vt1 dDate Fee I6 Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 I REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEELESS J9 PRORATION ' PLUS PENALTY OTHER OTHER Date Receipt No. Permit No. -- 1 nuance ate Mailed Delivered - -Re eived by 1691 E.14"ELTON AVE..P.O.eon 2009 STOCKTON,CA'S5201 APPLICANT—RETURN ALL COPIES TQ, ENVIRONMENTAL HEALTH PERMIT/SERVICES _ +-•- _imm+ —