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..pyaw......a vw ..o r.....��.. ....o,. .�.........o.. r oyc,q ., ,promo. oe ou.e .0 wyn i nu Hppncanun. FOR OFFICE USE: APPLICATION :or Non-Transferable, Revocable, Suspendable).� PUMP&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 Coun rdi�nce o.18 2 and a rules and regulations of the San Joa uin Local H Ith District. Exact Site Address Z77yD (�G/� a'/� L° (`,r City/Town �:<r�' 2r Owner's Name %�h&ez Q,Cfr Phone Address City Contractor's Name /� IP License4?W�Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL W" DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ O WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ - DISTANCE TO NEAREST: Septic Tank Sewer Lines /40 Ot Pit Privy G Sewage Disposal Field Cesspirei/Seepage Pit Other a� Property Line:- �-f Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑,.,, I91-CABLE � INDUSTRIAL ®C BLE TOOL Dia. of Well Excavation M-60MESTIC/PRIVATE ULLED Dia. of Well Casing /Vill ❑n D DO�OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing rn Y+'n7RIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' 1 �'z ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By —� PUMP INSTALLATION: Contractor r " Type of Pump__ ,�' y� �sr H P PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth r 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. SS 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California:' ll for a Grout Inspection prior to grouting and a final inspection/./. Signed 1 ale: Dale: Z (Draw Plot Plan on Revers ide) FOR DEPARTMENT USE ONLY PHASE I Un Application Accepted By �d a--� Date CO f d Additional Comments: Phase 11 G out Inspection II Fin speetion Inspection By Date ��'�i�OGI Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT p. PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 0 0 ✓ LESS PRORATION PLUS PENALTY OTHER OTHER �?� Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ISM E.HAZELTON AVE.,P.O.Box Y STOCKTON,CA 95MI