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- nYYlll.a 11 V11a rW111 OV 1 1. 4VVasV nnen OMVt1O WU rl VYC117 VVI1110MMV. oC AV1Q 1 V 01911 1 NNW nPF 14%;arevll. FOR OFFICE USE: APPLICATION - �nor Non-Transferable, Revocable,Suspendable) �+ 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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address G 17 97,;k 2Z—> hQ i L3 City/Town i Owner's Name Phone Address .4 City ?Oe--r1-7, Contractor's Name ✓ ,.�� License# — Business Phone Contractor's Address mergency Phone Is Certificate of Workman's Compensation Insurance on File With S_ D? Yes k No COPY TYPE OF WORK (CHECK): NEW WELL❑" DEEPEN ❑ RECONDITIONLJ DESTRUCTION I L WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other r 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 Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I ❑ DISPOSAL ❑ OTHER p Other Information ❑ GEOPHYSICAL Surface Seal Itailed By: PUMP INSTALLATION: Contractor +lam Type of Pump H.P. PUMP REPLACEMENT: State Work Done �h'~ PUMP REPAIR: ❑ State Work Done 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 donein accordance with San Joaquin County ,ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. t I Home owner"`or licensed agent's signature certifies the following:1,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." I ill salt for a Grout Ins c-11 t h or o gro and a final inspection. Signed itle: ?,-1� Date: I Q/ (Draw Plot , an on Reverse Side) FOR DEPARTMENT USE ONLY 7 PHASE I ApplicatioDate / _ n Accepte y Additional Comme s: Phase 11 Grout Inspection Phase IH Final Inspection Inspection By Date Inspection By rte Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE b. AMOUNT DUE CHECKED DATE DATE ,REMITTED AMOUNT FEE S LESS PRORATION PLUS PENALTY OTHER _ I OTHER i g Received by Date .Receipt No. Permit No. I nuance Oate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 - _ I