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Appucanons wnl tie rrocessea wnen buommea rropeny l villp,e,eu. oc out, ,., y •-•rr••�---••• FOR OFFICE USE: APPLICATION +� +TPor Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVI.90NNTAL�E/1LTH PERN{kT (COMPLETE IN TRIPLICATE)�z • eM ENOW QI Application is hereby madetothe San Joaquin Local Health Districtfor F permit to consfructa /or install thework herein described.This application is made in compliancepith San Joaquin County Ordinance No. 1 862 and the rules and regulations of the San)Pagquii nocal Health District. Exact Site Address 7 G•s.3 h �/ -�• •61 i 1 C, City/Town Owner's Na 'L � AJ �N a K '� Phone •3 t�n '3 4=-7'7 1V Address Y O" / 'Q t^ fV rtL O City C &AA� 6 Contractors Name 1a1� pv �. oS� .ti `.� 4t. License License p/o �1 G.l Business Phone i✓J — �. 3 �'•] cb(b Contractor's Address/ ad !!a �\ 7K " 7-s Emergency Phone 71V-T' 1 3 )J Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes Z_� No TYPE OF WORK (CHECK): NEW WELL 3' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 V" REPLACEMENT❑ Y` DISTANCE TO NEAREST: Septic Tank Q it) Sewer Lines . /,SM Pit Privy Y Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 36— Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL _ ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavat 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ✓e ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal , � ❑ CATHODIC PROTECTION O-NOTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal sta By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State 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 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 subcontracting 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�will call for a Grout nspeclion prior to grouting and a final inspection. Signed X 607 c 3 - Title: �� Date. r (Draw Plot Plan on Reverse Side) FOR EPARTMENT USE ONLY PHASE Application Accepted By Date ' Z Additional Comments: ase 11 Or t Inspection Phase III Final Inspection Inspection By Date Inspection By � —(/JAL Date yy`�'/'y'�—,�'wJ — Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 8 Receivetl By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED d AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 7 �Z /6�d /s� R ived Dy Da Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—REMAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201