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wpplivaiions rral ne rrocessea wnemauomrneorropenya:.vmp1cVV.voau.v .v.-..yl. ..I`„r*,,,..•.•,... FOR OFFICE USE: `' APPLICATION r Non-Transferabie,'Revocable, Suspendable) PUMA&WELL nENVJRONMENTAL HEALTH PERMIT r,: (COMPLETE IN TRIPLICATE T}„ ? ,� W"ATER,QUALITY Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work.herein described Thisapplicationis made in compliance with San Joa uin Co ty Or. ' ante No. 1862 d t e rules and regulations of the San Joaquin Local Hepith District Exact Site Addres 151 1 City/Town Fs�il•�-t� Owner's Name Phone.: � D "•7�� -` I�/)- 3'�J_ Address City ,v; Contractor's Name LS-C.e # TYo» Bu nes Phone 7 r Contractor's Address Emergency Ph�ofn 2 / Zd Is,Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No TYPE OF WORK (CHECK): NEW WELL'❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 W I REPLACEMENT�. DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy FILE. COPY Sewage Disposal Field Cesspool/Seepage Pit Other Property_Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL - Dia.of Well Excavation 01 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4 ❑ IRRIGATION 11 GRAVEL PACK Depth ofi`Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other'Information ❑ GEOPHYSICAL Surface-Seal Installed By: PUMP INSTALLATION: Contractor Type,of Pump H.P. PUMP REPLACEMENT: State Work Done x cTt T., tnu �• +�� -�� s -- PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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 f ordinances,state laws, and rules and.regulations of the.San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fot)owing:"I certify that in the performance of the work for which th is permit S 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 certifiewthe 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." - all for a Grou p n prior to grouting and a final inspe Iw ' Signed X Title: -. Daie: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE f �i Application Accepted ` Date.- E Additional Comment c. Ph!srout Inspection £. h eA1I Final Inspects Inspection By— 1rispection By Dake Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By"July 31 - - REMIT BILLING REMITTANCE S,- ° ? ! l BASE EXPLANATIONAMOUNT DUE CHECKED DATE DATE` REMITTED AMOUNT F FEE S IS ; 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 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 I