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Applications Will Ue Processed When Dubmltted Properly Completed. Lie Dwe To Sign The Application. rTi APPLICATION `r (For Non-Transferable, Revocable, Suspendabl►� PUMP &WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) 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 wi San Jo quin C my Ordinance No. 188 d the rules and regulations of the San Joaquin Local Health District. Exact Site Address Vill g &f1'/2TC`'� Y- b City/Town � Owner's Name L7- /V/-1L4ff.440 / Phone Address /v S. U l tD 10 City lin 06 ea TD , Contractor's Name - nse l Business Phone OIF Contractor's Address t S G'5 Emergency Phone aD rr 7 �R lKqty I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I No T TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IX PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other 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 Gauge of Casingd ya IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal p ❑ CATHODIC PROTECTION 11 ROTARY. Type of Grout _ _ W ❑ DISPOSAL ❑ OTHER Other Information ._ p ❑ GEOPHYSICAL IAL �� Surface Seal Inst By: PUMP INSTALLATION: Contractor E--L./�' - Type of Pump ! - H.P. 7e _ PUMP REPLACEMENT: ❑ State Work DoneJ/v',g PUMP REPAIR: ❑ State Work Done -7 DESTRUCTION OF WELL: Well Diameter i� Approximate Depth Zan Describe Material and Procedure <� A ,4Lt L 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. Home owner or 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." Contractor's hiring or sub-contracting signature certifies 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." 'Ail'call for a Groulf4frispectio4prior to grouting and a final inspection. t Signed X 2 Title: i@ , t'OsZ L-1 Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI 1 Application Accepted By aAo Additional Comments: Phase H Grout Inspection P e II al Inspection ��[ Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A ived By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ,eiL LESS PRORATION PLUS PENALTY OTHER OTHER Al 3 y Received by I Dal Receipt No, Permit No. Issuance Date Mailed Delivered 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE,P.O.boa 100 STOCKTON.CA 95201