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rM APPLICATION(For Non-Transferable,Revocable,SuspendatyPUMP&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 Saodoaquin District. Exact Site Address._�� 12 �- My -� City/Town & Owner's Name ifiv.4ift 63a�6 Phone�zgls Address aya� t _IV I:N6 i" City � Contractor's Name "YYt Q144W6hse g!1S*J6Z Business Phone ! �r� Contractor's Address Aif, Q " '4 44"AAAMWIFirgency Phone Is Certificate of Workman's CompensationIns rance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank -627C_— Sewer Lines f Pit Privy�Q t Sewage Disposal F� f Field �� ' ' Cesspool/Seepage Pit Al/0'"' ther A-1 Property Line.J�fZ Private Domestic Well� Public Domestic Well /L/ INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Aa •,"r DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing ❑ IRRIGATION IV GRAVEL PACK Depth of Grout Seal ayr ❑ CATHODIC PROTECTION Ir' ROTARY Type of Grout 4r- A7-El DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: TV I� N PUMP INSTALLATION: Contractor MLG"�`�f Type of Pump 5 13 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth s� 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, 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 forwhich this permit is issued, I shall emp persons subject to work anis compensation laws of California." 1 wl l I for a Gr dl Ins on or to luting a d final Inspe� Signed X Title: Date: ' (Draw Plot Plan on Reverse Side) FORD PARTME USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase 11 Grout Inspection ha I Final j�ec�tionn Inspection By Vbekr " a '^ Dat ��rj` Inspection By ate I2411 L- � r•-+'�'dcn� �a�lSl�i / Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 0 a' LESS PRORATION PLUS PENALTY OTHER OTHER cs -7q-9ek sia�i'�t Received by Date Rmelpt No, Permit No. Issuance Date Mailed Dellvemd APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 161111 E.HAZELTON AVE.,P.O.aex 2009 STOCKTON,CA 96201 _