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FOR OF9CE USE: APPLICATION I 'For Non-Transferable, Revocable, Suspendable` [ice ENVIRONMENTAL HEALTH PERMIT 1.40 PUMP&WELL L(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 app made in compliance with San Joaquin County�O jdinsr]ce No. 1862 and t e ules and regulations of the San Joaquin Local Health District. Exact Site Address � 3 a �,vT � City/Town C-a r»n a Owner's Name I Al Phone 3(m F' 14a 4S 6aAddressAP it d i�. AJ /p City '44--er m a Contractors Name aii Isyk� JO-tt �License#.SBI 23 Business Phone eq 2 Contractor's Address.7Aoop /✓' .S2J�S AkAnftEmergency Phone A10AJf!. `ris Certificate of Workman's CompensationIns rance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ `REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank .7-46,11111 Sewer Lines AE)el Imo— Pit Ptr�ivXy lVf0/4"Q— Sewage Disposal Field AVO AA_ cesspool/Seepage Pit IC.10 � Other Property Lin Private Domestic WellA)&rt e. Public Domestic Well 100,n _ ElkINTENDEDUSE TYPE OF WELL ❑ NDUSTRIAL CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing AR l- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Gv»[� `❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Su face Seal Installed B t P- 4A I �� Yi PUMP INSTALLATION: Contractor • 4/ ///Ci. T--L! -1//i AJ Q Type of Pump ell C&Id H.P. 70')4, �• PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ Stale Work Done 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 rn ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 6. 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." IIwwcall for a Grout Ins ctio/�nn prior to grouting and a final Inspection. Signed X ( �( (L� Ins � � Title: ` 4l— 4Z4J'3t.R'�� Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I ` Application Accepted By Q I Date ' Additional Comments: • II Groul Inspection O hast F al Inspection Inspection By DatZAI�AIb ` e Inspection By yIili9ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 A Received By July 31 REMIT BILLING REMITTANCE $L BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE6 0 LESS LPRORATION PLUS PENALTY OTHER I• OTHER M Received by Date I Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201