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..yy,.wuwn ao..ve r,weaasu ancon wmu, r r,vyeuy v.vury.weu. oc ww ,u myn i ue r�yynuauon. FOR OFcICE USE: APPLICATION For Non-Transferable, Revocable,Suspendable PUMP &WELL % ENVIRONMENTAL HEALTH PERMIT(COMPLETY Application slheeby made to the San Joaquin Local Health DistrictfN TRIPLICATE) ora perrATERmitlto QUALITY install thefo��r� del� no app . made in compliance with San Joaquin County O dins4ce No. 1862 and t e ules and regulations of the San oaquin Local Health District. Exact Site Address /�3.0 J—W �cJT ,�� City/Town 00vad Mile- o Owner's Name hi F9 L iN G Phone 36 f= G C AddressNa#) O N City '4�--At rn OR D Contractor's Name . vie ki IJO-( /I i� � License#.�}8/A3 Business Phone --?4 Contractor's Address-0-00 �• -5e M/brE( IQCn I7fOAEmergency Phone /VeiLI e. Is Certificate of Workman's Compensation In ranee on File With SJLHD? Yes No S TYPE OF WORK (CHECK): NEW WELL., DEEPEN 1116".RECONDITION❑ DESTRUCTION❑ _ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR -4z REPLACEMENT❑ n DISTANCE TO NEAREST: Septic Tank Sewer Lines/64MP� Pit Privy A).0 Sewage Disposal Field IVO iU�°_ Cass .,IoIoi/Seepage Pit �O AA%-- Other Property Lin Private Domestic Well N®/Z� Public Domestic Well USE TYPE OF WELL ❑ NDUSTRIAL CABLE TOOL Dia.of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /a Q ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout .O=v AIAI- 11 DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Q Surface Seal Installed By , !" PUMP INSTALLATION: Contractor A 9 �Lf d/Ci, le / /^:/1i ly C Type of Pump 4�enr b/r H.P. 1 I*- 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. 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 employ persons subject to workman's compensation laws of California." I w call for a Grout I,ns�tion prior to grouting and a final inspection. Signed X �j�tF��1 I&OZ Title: �— Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Are- - I Date -V Additional Comments: - 11 Grout Inspection O hsaction n6 Inspection By Dately Inspection By to 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 DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE al a G LESS PRORATION PLUS PENALTY OTHER OTHER Received by bate I Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON,CA 95201