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L Applications Will Be Processed When Submitted Properly Co 41u ''TA!gn The Add L' tion. ?OR orFICE USE: ARPLIrATIOw (For Non-Transferable, Revocable, Rdablp� 15X980 �% OZ ENVIRONMENTAL HEALTH PERMIT 1 pLPUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY SAN D(�T RIS JqWJ Application is hereby made to the San Joaquin Local Health District fora permit to construct and/"pmatl tfle work herein described.This application is made in compliance with San Joaquin C$unty QTdipance IVo. 1862 and the ryles and regulations of the San Joa uin Local Health District. I. Exact Site Address le)� z IS — /�L`�Af?i' X —4, low. — L/el ��Z✓7 Owner's Name - ski o Phone Address -S / City t. Contractor's Name kJ 120 e9a kif icense#�� Business Phone 'fes/—3� /D Contractor's Address 4F Emergency Phone Is Certificate of Workman's Compensation Insur nce on File With SJLHO? Yes /s No TYPE OF WORK (CHECK): NEW WE[ DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �Q REPLACEMENT❑ Q DISTANCE TO NEAREST: Septic Tank / /// s la t✓ Pit Privy Sewage Dispo I Field !�sewer Lines of/Seepage Pit --heellIZ 1770the, 7�,I Property Line. Private Domestic Well y -Ar I'Public D mestic Well ell Z1 "� I INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation �5�s�61X ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing ✓' <tG�/ ...❑www DOMESTIC/PUBLIC DRIVEN Gauge of Casing ze IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information Q ❑ GEOPHYSICAL ��j � surface Seal Installed By: QlAd,�"s ll lax, PUMP INSTALLATION: Contractor_YIA.[?EJ YIN,# s �R",W" Type of Pump_�v� •°i-r r' H.P. l/© PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ` 1 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. Homeowner 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 employ persons subject to workman's compensation laws of California." 1 wiuAall fol a Grout Inspection prior to grouting and a final Inspection. >. Signed X " nt- Title: Date: + tw Plot Plan on Reve se Side) R DEPARTMENT USE ONLY War PHASE I ApplicAtion Accepted By Date O s 8 ACCi6onal Comments: Phase II grout Inspection � � Phase III.F.inal Inspection Inspection By ( lai / �pectioa By.— - Jyag� )ku Fee Is Due: ❑ ANNUALLY ❑ PER UNIT la PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July/H Received By July 31 REMIT NG REMITTANCE E BILLI BASE EXPLANATION O E DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE fl- - at JP LESS PRORATION PLUS PENALTY l �" 1 _ OTHER h C I OTHER — Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 -