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ApplicationsWill BeProcessedWhen Submitted Properly compeiea. be cure Io agn Ino^MH FOR OFFICE USE: �p /0 n APPLICATION An �tNon-Transferable, Revocable, Suspendabli PUMP&WELL ENVIRONMENTAL HEALTH PERMIT , (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application SIA made in compliance with San Joaquin County Or_diLrf�once No. 1862 and the LruJles and gulations of the San Joaqul Loc Health /,II��a act. Exact Site Address �� 7� ,lir i:�e �Sr^e sJ t M1d� City/Town Pf,2 Owner's Name -r Phone 535 —G/ 7 Address ,[C/��t-eJ� �e• City di10 edf �� `K[r 413 Contractor's Name " s License#143-7�, BusinessPhone SL(i1 —767 G Contractor's Address '.\a Z C4 G xsv- -'AJMV Emergency Phone Is Certificate of Workman's Compensation Insurance on File With S HD? Yes— 'Ir No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION III PUMP REPAIR❑ N REPLACEMENT❑ J DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well �J INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation JiI 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 V,// r w Type of Pump S A4 d,An H.P. PUMP REPLACEMENT: ❑ State Work Done x PUMP REPMR: 15 State Work Done the E # Wo 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 the work for which this permit is issued, 1 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 thework forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California" will call for a Grout Ins €c c, nor to routing a final inspection. Signed �,. ` 'r t� s & Title: ?rK✓ Date: (Draw t Plan on Reverse Side) FOR PART NT USE ONLY � � PHASE I 79 Application Accepted By Date � Additional Comments: Phase II Grout Inspection Ph a 111 Final Inspection Inspection By Date Inspection B� Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 29 PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July i &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER -79 9g I I/ l/ 71 Received by Date Receipt No Permit No. Issuance Oat- Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Box 3009 STOCKTON,CA 95201