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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. PFOR ;?FFICE IJSE: "-t APPLICATION i, ( `or Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL. HEALTH PERMIT 1 ~ WATER QUALITY (Cisv4• . INTRIPLICATE) Applica -shereby madetotheSanJoaquinLocal Health Districtforapermittocoristructand/orinstaflth orCu made in compliance with San Joaquin C my Ordinance 1 2 and the ru s and regul tions of the San e i Exact Site'AddressCX u `7F l -- Owner's Name Ph ne Address City_ --- contractors Name License# 'c�2gW3 Business'Phone 6 _ 1r � I Contractor's Address E ergency Phone i1 is Certificate of Workman's Compensation insurance on7Fihl' Yes X No" 11 - TYPE OF WORK (CHECK): NEW WELL" DEEPRECONDITION❑ DESTRUCTION❑ f1 WELL CHLORINATION ❑. WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION 13 PUMP REPAIR El REPLACEMENT❑ 16. DISTANCE TO NEAREST:' Septic Tank Sewer Lines Pit Privy 1 Sewage Disposal Field Cesspool/Seepage Pit Other Ea 1. Property Line Private Domestic We11 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL �9 ❑ CABLE TOOL Dia. of Well.Excavation X DOMESTIC/PRIVATE II 11DRILLED Dia. of Well Casing �� ' r 6 ❑ •DOMESTIC/PUBLIC "❑ DRIVEN Gauge of Casing ❑ IRRIGATIONGRAVEL PACK. Depth of Grout Seal r. d ❑ CATHODIC PROTECTION ,ROTARY Type of Grout ' U `i ❑ DISPOSAL ❑ OTHER Other Information- 4 !� ❑ GEOPHYSICAL ; Surface Seal Installed By: 1 ;I 3 PUMP INSTALLATION: Contractor I� Type of Pump H.P. i PUMP REPLACEMENT: 1; ❑ State Work Done 1 PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth l—•-, :-- _.------_—__--Describe-Material-and Procedure-- - _...__-- - - - -__-----•-- ----.�_.. -- --.__�—� 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." lh 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. 1 will call fora Grout Insp on prior to g outing and a final inspection. j Signed X Title: Date: ID//.Z/.,3 ( aw Plot Pian on Reverse Side) t FOR DEPARTMENT USE-ONLY / PHASE 1 Application Accepted By 1� Date Additional Comments: %eiou�tlhspection Phase III Final Inspection � Inspection By n'! - Date By Date �Fee Is Due:'0 ANNUALLY .,i�❑.PER UNIT.,. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1-a Received By July-31 �� BILLING REMITTANCE REMIT BASE- EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT i FEE I� .� LESS !l. PRORATIONPLUS 11 it PENALTY OTHER i OTHER !I - Received by Dale�l Receipt No. .Permit No. 1 Issua ce Date Mailed Delivered f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 05201 r!� II