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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFJCE USE: APPLICATION 1_ w. C (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE)1 3`Q 5-cf s.7F ,fir c/C,QrLiJ!ATER QUALITY ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance w' h aq County Ordinan 1862 and ule and regulalie�[ati of the San Joaquin Local Health District. Exact Site Address W_ _ U City,Town Owner's Name100, U Phone P`— AddressQ _ _ - City /Jew C i Contractor's Nam .. (rc nse#3:;�/ Business Phoneiry Contractor's Address : _ ergency Phone 3 Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes tom----- No _ �~ TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1�ir PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST. Septic Tank/Qd ::7L Sewer Lines -- Pit Privy - Sewage Disposal Figid�/0 0 -- 74- Cesspool/Seepage Pit Other Property Line/ Private Domestic Well Public Domestic Well --t- INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation44 !' OMESTIC/PRIVATE 11DRILLED Dia. of Well Casing IV ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �6) 7 Q ❑ CATHODIC PROTECTION Q'ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Sr7l Installed By: _cC;h .C✓o S. /rtr( PUMP INSTALLATION: Contractor�i> .Z7 //Y Un�>P • o Type of Pump— H.P. —' f F PUMP REPLACEMENT: 13 State Work Done PUMP REPAIR: ❑ State Work Done _- DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure _ 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County'4� ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. T � F Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit �1 is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 'r+ 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 empE5t workman's compensation laws of California," I I call for a Gro and a final inspection. Signed X Title: ,ClFz(\rfib�� Date:Plot Plan on Reverse Side) i t � FOR DEPARTMENT USE ONLY PHASE Application Accepted By— Date / �6 Additional Comments: Phase II Grout Inspection �a".1 Final Inspectio Inspection By__. Date Inspection By //J_ Date - ��55 t Fee Is Due: ❑ ANNUALLY C1 PER UNIT ,cu 'ER SITE ❑ EACH ❑ January 1&Rec_ By January 31 ❑ July i&Received By July 31 h BASE EXPLANATION BILLING REMITREMIT TANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION 2 PLUS PENALTY OTHER ` OTHER Received by Dald Receipt No. Permit No. Isatiance D6te Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201