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k4 Applications Will Fie Processed When Sabmllled Pr-Percy Completed.tae Sure To Slgn The Application, FQR OFFICE USE: APPLICATION (For Non-Trans:erat!:e,Revocable,Suspendablej PUMP&WELL ENVIRONMENTAL HEALTH PEAMIT (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 wj/i San Joaquin Count Ordinance No, 1862 nd the ru se s and regulati ,bt the San Joaquin.Local Health District. Enact Site Address J_" +u±a?A>_L.' Z Gr 4� , __�Ls'.lf��y ��ci!I4'l�� Ifawre •� 1 TC1((fyQ/p .t � � ' Owner's Name � � �1';.(��.f;G?.7!/r^�.? J I Phone Address /10 �'f�' _ Cir S-- ,q I t — Contractor's Name ._�L r - i �r1�. License a y �' A `_Business Phone Contractor's Address � y rgenc Phone Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes�� No _ o� TYPE OF WORK (CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION❑ f� WELL CHLORINATION❑ WELL ABANDONMENT O OTHER ❑ PUMP 1NSTAL�_ATION❑ . PUMP REPAIR❑ 1 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank jn"' $ewer Lin3s Pi!Fr;, Sewage Disposal Field ' Cesspool/;}eepage Pit Other Property Line __Privrete Domestic Well __—_ Public Comestic Well _ j' INTENDED USE TYPE OF WELL . r/ INDUSTRIAL C1 CABLE TOOLDia.of Well Excavation r 0 DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing {, ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing it �SS►^ffl ❑ IRRIGATION V GRAVEL PACK Dvpth of Grout See! ❑ CATHODIC PROTECTION ROTARY Type of Grout _ - ❑ DISPOSAL ❑ OTHER Other Information lCL _ ❑ GEOPHYSICAL Surface Seal Installed Ey: I/?� 1 ' PUMP INSTALLATION. Contractor � Type of —� -= — YP 'Pump --- H:P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ -.;ate Work Dore L_ oESTf3UCTION OF WELL: We::Diameter------ Approximate Depth 4? Describe Material and Procedure ' I heceby certify that I havo prepared this aoplication and.that the work will be done in accordance with San Joaquin.County ordinances.state laws,and rules and regulations of the.San Jaa4Lin Lo lal Health District. v Home owner or licensed agent's sfgnature cedifles the following;"I certify that in the performance of the work for which this permit is issued, I shall not emplo)capy,persoR:n such manner as to beCame Subject to workman's compensation laws or California." Contractor's hlifn orsub-contracting si iiaiure certifies the following. certify!ha! •;� 9 9 g� g:"I certif ha±in the performance of the work for which this ' permit is issued.I shall employ persons subject to•r:orkman'c compensation laws of'Caiifornia." ' r' Icall for a Grout In Lion prior t grouting and a Fina Inspectlon ^ Signed xWitfL iLi-j— Title: II J L Date: J(Craw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY =: PHASE I Application Accepted By_ W Date _ Additional Comments:----------- V omments:—_— _ _ a ro+d Inspection Phase II!Final Inspection — c Inspection By Date_ / =__— Inspection By 9 Date L - Fee In Dile-❑ ANNUALLY ❑PER UNIT. ❑ PER SITE ❑ EACH _ ❑ J"a y 1 6 Received 3y January?1 ❑,July 1 8 Received By July 31 LONC i REIZITTANCE j; '_ _IT_ BASF. EXPLANATION RlI AL10UN7 DUE — CHECKE6 DATE DATE - �,,,REd117YED � �---_.`_ AMOUNT FEE LESS —k PRORATION PLUS C �^'7 } PENALTY ;.� OTHER 4 _ I OTHCH 4' Rece-veo by Oa4e Rece,pt No P—.1 N., Issuance Dr:e L_ Apl INT—RETURN ALL COPIES TO: ENvInONMkr4TAL HEALTH PEAAUTr5EAVrCE5 tW1 E.HAZWrON AVE... O.Bol tsoe STOCKTON.CA 95701 1' •9 i �,I