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FOR OFFICE USE: J-may/ APPLICATION n Zp iP1.B �O ` For Non-Transferable, Revocable,Suspendable J+ ((__ �..i 111111'IF PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY r Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application 1 04 made in compliance with San J^oa uin County Ordif ante No. 1862 and the sand gulations of the San Joaqui Loc Health s/ty,Ict. Exact Site Address T. / �l G./�e �Tr-� de City/Town r W{ '21111 ' owner's Name — t 1 1 Phone =A1 7 7 Address �R0�3 501WACity Al!` Ib' nt T S'SAQ Contractor's Name License# —7V-1 Business Phone "ii — 7467 G Contractors Address .2,a�p 5.0 1!H Emergency Phone Is Certificate of Workman's Compensation Insurance on File With S HD? Yes No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ \ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION R1 PUMP REPAIR❑ REPLACEMENT❑ J DISTANCE TO NEAREST: Septic Tank Sewer Lines T. Pit Privy �. Sewage Disposal Field Cesspool/Seepaglk Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL - Dia.of Well Excavation JI DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK - Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor gVVIIJ 40r Type of Pump .S*t 66.doz e,"lb H.P. PUMP REPLACEMENT: ❑ State Work Done ` PUMP REPAIR: h State Work Done SA-IfL m """" `„ A 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, t shall employ persons subject to workman's compensation laws of California." - will call for a Grout Ins c'o •tor to�r uting a final inspection. Signed Title: ?Insw Date: 04 (Draw F46t Plan on Reverse Side) FORD PART NT USE ONLY PHASE I ' / 9 Application Accepted By Date Additional Comments: Phase II Grout Inspection Pha a III Final Inspection r / Inspection By Datee Inspection B� Date ld Fee Is Due: ❑ ANNUALLY ❑ PER UNIT f_r PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION. BILLING REMITTANCE & AMOUNT DUE CHECKED ! DATE DATE REMITTED AMOUNT FEE xr LESS PRORATION PLUS PENALTY OTHER OTHER 79—i 98 11/ 1/ 71 Received by Date Receipt No. Permit No. Issuarvoe Date Mailed Delivered APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1591 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201